**Resp & Qualifications**

**PURPOSE:**
This role manages the appeal process for members and providers who appeal on behalf of members for government program lines of business. Ensures quality management of the clinical appeal process to reduce the risk of State and Federal Regulatory fines and sanctions, avoid adverse exposure, reiterate the expectation of a fair and compliant appeal process for our membership, and support NCQA accreditation and the Divisional Goals for Health Services. Ideal candidate will have minimum of three years of government program (Medicare/Medicaid) appeal and grievance operational oversight. We are looking for an experienced professional in the greater Baltimore metropolitan area who is willing and able to work in a hybrid model. The incumbent will be expected to work a portion of their week from home and a portion of their week at a CareFirst location based on business needs and work activities/deliverables that week.

**ESSENTIAL FUNCT...