1101 Vermont Ave NW Suite 1200 Washington, DC 20005 Kids Are Our Everything. Department 10513 HSCSN - Administration Pay Range $48,672.00 - $81,120.00 This position manages the day-to-day operations of the Appeals and Grievances operations for our Medicaid Health Plan - HSCSN. Assures that the department is compliant with all regulatory requirements, manages turnaround times, submit reports to the executive leadership team, develops strategies to improve processes. This position has three direct reports and is a hybrid telework position. Qualifications - External Minimum Education Bachelor’s degree - required Bachelors Degree in healthcare related field - preferred Master's Degree- preferred Minimum Work Experience 5 years Appeals and Grievances experience - required 3 years Managed Care experience - required 3 years Acute, Med-Surg, or Ambulatory care experience in a clinical role - preferred Required Licenses Registered Nurse DC preferred/Compact - preferred Required Skills/Knowledge • Knowledge of health care evaluation methodology, medical terminology, and regulations • Strong organizational, analytical, and data management skills, including word processing, spreadsheets, monitoring and evaluation tools • Detail oriented and organized with a strong sense of follow-up and completion. • Experience using time management skills to prioritize/organize and track details and deadlines of multiple projects with varying completion dates. • Clinical experience that has been either recent, lengthy/and/or diverse • Awareness of health care industry trends and strategies • Fluency in electronic medical record documentation of clinical care • Clinical experience with acute care and ambulatory care operations • Knowledge of InterQual criteria • Ability to communicate effectively (verbal and written) with individuals internal and external to the organization. • Conflict Management skills and self-confidence for resolution of outcomes with dissatisfied patients/customers or those for which an outcome was sub-optimal • Expert verbal and written communication and presentation skills • Strong analytical, organizational, and interpersonal skills. • Advanced proficiency with Outlook, Microsoft Excel, and Word applications • Supervise the Grievance and Appeals team to ensure appropriate handling of member appeals and grievances. • Serves as the organization’s subject matter expert on the Chart Retrieval & Clinical Review platform, including interactions with and impacts on adjacent services. Maintains appropriate documentation to meet regulatory reviews. • Ensure that all appeals and grievances are investigated thoroughly and resolved in compliance with regulatory requirements. • Conduct periodic reviews and audits to ensure quality and performance standards are met. • Develop and maintain records of appeals and grievances for reporting and auditing purposes. • Prepare and submit documents in response to fair hearings processes and requests; engage internal legal counsel as necessary. • Prepare and develop reports for, and present to, management related to appeals and grievances and fair hearings. • Ensure strict adherence to contractual requirements and Medicaid regulations, policies, and procedures. • Stay informed about changes in health care regulations related to appeals and grievances, and update processes accordingly. • Prepare and submit required reports to regulatory authorities regarding appeals, grievances and fair hearings activities. • Provide guidance, mentorship, and training to appeals, grievances, and risk management staff. • Foster a culture of compliance, quality improvement, and patient-centered care. • Identifies potential conflicts when reviewing and resolving appeals and grievances and escalates such conflicts to appropriate leader for review and resolution. • May perform other duties in addition to those outlined in this job description. DC RESIDENTS ENCOURAGED TO APPLY The disclosed salary range includes the minimum and maximum rates within which Children’s National believes an individual’s base pay rate will fall for this position. It is not typical for an individual to be hired at or near the maximum of the pay range. The exact pay rate for this position will be based on a variety of factors in alignment with the Children’s National compensation philosophy. These factors are legitimate and non-discriminatory including, but not limited to, the current market conditions; organizational needs; the individual’s combination of prior work experience, level of education, knowledge, skills, and other qualifications. Children’s National is committed to providing a fair and competitive total rewards package to each of our employees. This base salary range does not include our comprehensive benefits package or any additional compensation for which this position may be eligible. Childrens National Hospital is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender, identity, or other characteristics protected by law. The “Know Your Rights” poster is available here: and the pay transparency policy is available here: Know Your RightsPay Transparency Nondiscrimination Poster. Please note that it is the policy of Children's National Hospital to ensure a “drug-free” work environment: a workplace free from the illegal use, possession or distribution of controlled substances (as defined in the Controlled Substances Act), or the misuse of legal substances, by all staff (management, employees and contractors). Though recreational and medical marijuana are now legal in the District of Columbia, Children's National and its affiliates maintain the right, in accordance with our policy, to enforce a drug-free workplace, including prohibiting recreational or prescribed marijuana. Thank you for your interest in joining our exceptional team at Health Services for Children with Special Needs, Inc. (HSCSN). We are committed to providing the personalized attention and high-quality care our enrollees need to lead fulfilling lives. Introduce yourself to our recruiting team, and we will reach out to you if a role aligns with your skills and experience. About Us Health Services for Children with Special Needs, Inc. (HSCSN) is the managed care plan contracted with the District of Columbia to administer the Child and Adolescent Supplemental Security Income Program (CASSIP) for children and young adults to age 26 years. HSCSN's mission is to coordinate innovative, high-quality, community-based care for individuals with complex needs and their families. HSCSN empowers all we serve to improve the quality of their lives. For more information about HSCSN, visit the website: HSCSN Health Services for Children with Special Needs | Health Services for Children with Special Needs, Inc. (HSCSN) (hscsnhealthplan.org) Recruitment Fraud Notice As fraudulent recruitment activities by individuals or organizations falsely claiming to represent hospitals are on the rise. Please be advised that: Official Communication: All legitimate communication regarding job opportunities will come from our official email addresses and website. Any correspondence related to Health Services for Children with Special Needs, Inc. from a personal email such as Yahoo, Gmail, iCloud, etc. is fraudulent. Application Process: We will never ask for payment or personal financial information as part of the recruitment process. All applications will be submitted through our applicant tracking system and can be found on our careers site. Careers. Verification: If you receive any suspicious communication, please verify its authenticity by contacting us directly at talentacquisitionconsultants @childrensnational.org Your safety and security are our priority. If you suspect recruitment fraud, report it to us immediately.

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