Job Closed
This listing is no longer active.
Quantum Health offers solutions and expertise to help consumers navigate the healthcare system. The award-winning company has hired in the past for 100% work-from-home opportunitie
Director, Appeals
Location
Ohio
Posted
52 days ago
Salary
0
Seniority
Lead
Job Description
Director, Appeals
Quantum Health
• Develop and implement strategic plans for the clinical appeals program aligned with organizational goals • Lead a team of clinical reviewers, nurses, and support staff in managing appeals and grievances • Serve as a subject matter expert on clinical appeals, providing guidance and training to staff and leadership • Provide daily oversight and support to the teams • Ensure that all appeals and letters are completed within required timeframes • Develop and review monthly reports to ensure compliance and to identify any trends • Work with TPA partners to develop necessary workflows • Oversee the end-to-end appeals process, including intake, clinical review, documentation, and resolution • Ensure compliance with URAC and other regulatory bodies • Monitor performance metrics (e.g., turnaround times, overturn rates, quality scores) and implement process improvements • Review complex cases and provide clinical expertise in appeal determinations • Collaborate with Medical Directors and external physician advisors for secondary reviews • Maintain high standards of documentation and clinical rationale in all appeal responses • Liaise with payers, providers, and internal departments to resolve escalated cases • Partner with Legal, Compliance, and Quality teams to address regulatory inquiries and audits • Represent the appeals function in cross-functional committees and initiatives • Provide reporting for Client Executives for their groups; maintain monthly appeals/non-certification reporting • All other duties as assigned.
Job Requirements
- Professional designation as RN, NP or CEBS preferred
- Minimum 7 years of healthcare experience, with at least 3 years in utilization management or appeals
- Strong knowledge of InterQual and payer policies, (e.g. ERISA and the ACA)
- Proven leadership experience in a healthcare setting including leading people and teams
- Excellent written and verbal communication, analytical, and organizational skills
- Experience with electronic medical record systems and utilization management platforms preferred
- Strong analytical skills with the ability to interpret complex clinical data and translate it into presentation and actionable insights
- Exceptional presentation and communication skills, with experience presenting to clients
- Ability to work collaboratively with cross-functional teams and external consultants
- Strong organizational skills and the ability to manage multiple projects simultaneously
- Proficient in using healthcare data management software and audit tools
- A high degree of personal accountability and trustworthiness
Benefits
- Health, vision and dental featuring best-in-class healthcare navigation services
- Life insurance
- Legal and identity protection
- Adoption assistance
- EAP
- Teladoc services
- 401(k) plan with up to 4% employer match and full vesting on day one
- Paid Time Off (PTO)
- 7 paid holidays
- Parental leave
- Volunteer days
- Paid sabbaticals
- Tuition reimbursement up to $5,250 annually
- Certification/continuing education reimbursement
- Discounted higher education partnerships
- Paid trainings and leadership development
- Recognition as a Best Place to Work for 15+ years
- Casual dress code
- Open floor plans
- Full-service dining
- Free snacks and drinks
- Complimentary 24/7 fitness center with group classes
- Outdoor walking paths
- Game room
- Notary and dry-cleaning services
Related Guides
Related Categories
Related Job Pages
More Director Jobs
Engineering @ MergeCo As a Director, you will be responsible for setting and executing our engineering strategy over many platforms, ensuring we deliver high-quality, scalable, secure, and forward-looking solutions. This position requires strong leadership skills, deep technical knowledge, and the ability to manage a complex team structure. Specifically overseeing both Staff Engineers and Engineering Managers who manage their own teams. This role will report directly to the Chief Technology Officer (CTO). Day in the Life Strategic Leadership and Execution - Define and champion the long-term technical roadmap and architectural vision in alignment with company goals and product strategy. - Translate business objectives into clear, measurable engineering goals and initiatives. - Drive continuous improvement in engineering processes, tooling, and practices (e.g., CI/CD, unit testing, AI tooling) to maximize efficiency and delivery speed. - Manage the departmental budget, resource allocation, and capacity planning across all managed teams. People and Organizational Management - Mentor, guide, and evaluate Engineering Managers, fostering a culture of high performance, accountability, and operational excellence within their teams. - Directly manage and provide technical guidance to Staff Engineers, ensuring technical alignment and driving complex, cross-functional engineering initiatives. - Work with your peers to develop and execute a comprehensive talent strategy, including recruiting, retention, performance management, and career development across all roles within your engineering organization. - Cultivate a healthy, inclusive, and collaborative engineering culture that promotes innovation, psychological safety, and technical mastery. Technical and Operational Excellence - Establish and enforce rigorous standards for code quality, system performance, security, and scalability. - Oversee the architecture review process, ensuring that all systems are robust, cost-effective, and meet future business demands. - Act as a technical escalation point for critical issues, driving timely resolution while also communicating a comprehensive root cause analysis. Must Haves - Minimum of 10 years of progressive experience in software engineering, with at least 5 years in a senior leadership role managing managers (Manager of Managers). - Demonstrated experience in scaling engineering organizations and delivering complex, high-traffic, and distributed systems. - Proven ability to manage both direct individual contributors (Staff/Principal Engineers) and subordinate management layers. - Experience reporting directly to a C-level executive (CTO, CIO, CEO, etc.). - Exceptional strategic planning and execution skills. - Deep technical understanding across multiple domains (e.g., cloud infrastructure, microservices, data engineering, front-end architecture, AI/ML architecture). - Capable of engaging effectively with technical teams, executive leadership, and external stakeholders, demonstrating strong communication, negotiation, and influencing skills. - Strong financial acumen related to managing cloud infrastructure costs and departmental operating budgets. - A servant-leader mindset with a passion for mentorship and developing organizational capabilities. - U.S. Citizen or Permanent Resident status required. Visa Sponsorship is not available at this time. A Few of the Perks - Competitive benefits - Unlimited PTO - Remote work available for U.S.-based candidates - 401(k) with employer match - Paid parental leave - In-office benefits for those local to Dallas, TX: - - Catered lunches - Casual office atmosphere & located in the Design District - Fully stocked kitchen
Regional Account Director - DACH (m/f/d)
FlexFlex splits your bills into smaller, stress-free payments throughout the month. Start today with your rent bill!
Flex is the diversified manufacturing partner of choice that helps market-leading brands design, build and deliver innovative products that improve the world. A career at Flex offers the opportunity to make a difference and invest in your growth in a respectful, inclusive, and collaborative environment. If you are excited about a role but don't meet every bullet point, we encourage you to apply and join us to create the extraordinary. Job Summary Anord Mardix, a Flex company, are a global group that manufactures switchgear, busway and associated products for installation in mission-critical and live commercial buildings ranging from data centres to the international headquarters of some of the world’s largest companies. To support our extraordinary teams who build great products and contribute to our growth, we currently have a unique opportunity as we look to add a Regional Account Director – DACH (m/f/d) to further support our client base. Reporting to the Head of Sales EMEA, the Regional Account Director – DACH (m/f/d) will be responsible for strategically developing and managing multiple customers across the DACH region by engaging with our internal and external clients to manage and expand current business and develop new opportunities in order to deliver customer value, drive profitability and grow revenue. This is a remote role and can be based anywhere in Germany, focussing on the DACH region, whilst also supporting the wider EMEA region. What a typical day looks like: - To build and maintain new and existing relationships within the various electrical industry sectors across the globe - Understand client needs, identifying opportunities for growth, whilst developing strategies to deliver value and drive revenue - Develop plans and strategies for developing business and achieving the company’s sales goals - Create a culture of success and ongoing business and goal achievement to deliver profitable growth - Manage customer expectations and contribute to a high level of customer satisfaction - Provide detailed and accurate sales forecasting - Compile information and data related to customer and prospect interactions - Monitor customer, market and competitor activity and provide feedback to company leadership team and other company functions - Work closely with the marketing function to establish successful support, channel and partner programs - Manage key customer relationships and participate in closing strategic opportunities - Travel for in-person meetings with customers and partners and to develop key relationships The experience we’re looking to add to our team: - Strong technical sales experience, ideally within the Electrical Engineering or Critical Power industry. Other technical backgrounds such as UPS, Generator sales, cooling industry will be considered - Demonstrable ability to manage and develop key accounts, convert leads and sell technical products - Ability to read technical drawings and experience in liaising with design and estimating teams - Knowledge of Switchgear, Busway and the Data Centre industry is advantageous - Proven ability to manage key accounts as well as generate new business - Strong skills in both written and verbal communication - Creative, enthusiastic with a pro-active attitude and a keen eye for detail - Ability to build and retain strong customer relationships - Confident under pressure and able to handle multifaceted objectives What you’ll receive for the great work you provide: You’ll join a high-impact team, leading global performance. We offer a competitive salary, opportunities for career development, and a collaborative environment where your leadership and insights will shape the future of our commercial operations. At Flex, we welcome people of all backgrounds. Our employees thrive here by living our values: we support each other as we strive to find a better way, we move fast with discipline and purpose, and we do the right thing always. Through a respectful, inclusive and collaborative culture, a career at Flex offers the opportunity to make a difference, invest in your career growth and join our purpose -- to make great products that create value and improve people’s lives. TH10 #LI-TONYHYNES Job Category Sales - Marketing - Account Mgmt Is Sponsorship Available? No Flex is an Equal Opportunity Employer and employment selection decisions are based on merit, qualifications, and abilities. We do not discriminate based on: age, race, religion, color, sex, national origin, marital status, sexual orientation, gender identity, veteran status, disability, pregnancy status, or any other status protected by law. We're happy to provide reasonable accommodations to those with a disability for assistance in the application process. Please email accessibility@flex.com and we'll discuss your specific situation and next steps (NOTE: this email does not accept or consider resumes or applications. This is only for disability assistance. To be considered for a position at Flex, you must complete the application process first).
Director, Integration and Improvement – Physician Enterprise
Lehigh Valley Health NetworkLife is full of partners. Your health deserves one, too.
• Lead the integration of processes, workflows, and systems across the Physician Enterprise, ensuring alignment with the broader enterprise’s goals and objectives. • Collaborate with the Performance and Integration Management Office (PIMO) and enterprise teams to identify integration opportunities that improve operational efficiency and provider performance. • Develop and implement robust integration strategies to streamline operations, reduce redundancies, and enhance system interoperability. • Act as a liaison between the medical group, the health system operations, and university stakeholders, ensuring alignment and collaboration across all entities. • Partner with the PIMO to design and execute performance improvement initiatives that address inefficiencies and enhance outcomes across the Physician Enterprise. • Use data-driven performance improvement methodologies to identify root causes of inefficiencies and implement sustainable solutions. • Establish and track key performance indicators (KPIs) to measure the success of integration and improvement efforts, ensuring accountability and transparency. • Foster a culture of continuous improvement within the Physician Enterprise by engaging and empowering physicians, practice leaders, and administrative teams. • Build strong relationships with stakeholders across the medical group, health system, university, and PMIO to ensure alignment and successful execution. • Lead cross-functional teams to execute complex projects, ensuring alignment with organizational goals and timelines. • Develop and implement change management strategies to ensure the successful adoption of integration and performance improvement initiatives across the physician enterprise. • Monitor and address resistance to change, ensuring initiatives achieve long-term sustainability and success.
When our values align, there's no limit to what we can achieve. At Parexel, we all share the same goal - to improve the world's health. From clinical trials to regulatory, consulting, and market access, every clinical development solution we provide is underpinned by something special - a deep conviction in what we do. Each of us, no matter what we do at Parexel, contributes to the development of a therapy that ultimately will benefit a patient. We take our work personally, we do it with empathy and we're committed to making a difference. We are currently looking to recruit an experienced Director RWD Strategy - Europe to join us in select European locations Picture Yourself At Parexel: The Director, RWD Strategy – Europe is responsible for identifying and implementing innovative access to real-world scientific data (RWD) within the region of both broad and deep patient clinical domains. This includes being proactive and determining the best methods for partnering with health systems, data vendors, national/regional patient registries, disease-specific registries and other novel sources of real-world scientific data. This is an advanced role that requires hands-on RWD experience and leadership competencies, accountability, relationship management skills and business acumen. Individuals must ensure that the application of RWD for a given solution is fit-for-purpose and is used in a manner compliant with the data use agreement and applicable law. The Director, RWD Strategy – Europe will be enthusiastic and hands-on to develop high quality proposal material, engage with clients during bid proposals meetings, partner with multiple data partners across the region, and create RWD strategies for the region. This role offers keen insights into innovative methodologies such as AI use in RWE, PASS and therapy area applications using RWD as well as specific expertise in EMA regulatory guidance to chart a successful path forward for generating evidence from RWD. What You'll Do At Parexel: Proposal Development | Science | Data Insights | Vendor Management: Proposal Development and Client Bid Proposals - Responsible for hands-on development of high-quality, client-ready RWD Strategy-related materials for client opportunities via PPT and Word documents - Attend and represent RWD Strategy for Europe opportunities with clients - Identify opportunities where RWD will be a value-add and positioning RWD Strategies to deliver winning solutions Scientific and Real-World Data Asset Access - Responsible for the execution of a global RWD acquisition strategy within the region - Solution for gaps in Parexel’s scientific and real-world data coverage. Identify, assess, and recommend options to expand access to RWD and scientific data to fill gaps in Parexel’s coverage within the region - Perform return-on-investment assessments that inform decision-making on whether to strategically partner with select data providers - Operate governance frameworks for regional RWD partners and suppliers - Responsible for specifications being up-to-date in the data catalog (e.g., new functionality), as well as training and use across business partners - Ensure that data access and use is fully operational - Evolve regional data acquisition with business partner strategy and needs - Monitor KPIs used to ensure impactful use of data. Remediate to deliver return-on-investment as required Vendor / Provider management - Monitor partner capabilities and services, making recommendations on ways in which the partnership can be strengthened (e.g., improve direct access, feasibility turnaround) - Work with Procurement/LRM to establish/manage qualification, due diligence and contracting - Follow up on how projects are going and what can be improved in terms of the PXL-partner relationship - Suppliers at minimum to include EMR / EHR; claims; pharmacy; lab, specialty data such as biomarker, genetic, and imaging; registries; clinical outcomes assessments, investigators or expert networks and similar sources of patient data beyond randomized clinical trial data Infrastructure & Platform Design - Partners with technology teams to ensure region-specific requirements for system architecture are met - Contribute to descriptive content that can be used in capability presentations, proposals, protocols/SAPs, study reports, etc. - Identifies and surfaces regional observations and trends that can inform further growth Relationship Management - Develop and maintain working relationships with SDO core solutions teams and functional teams, Parexel business partners, clients and vendors, providers; at minimum, Legal and Risk Management, Procurement, Data Privacy, Project team personnel - Maintaining relationships with regulatory bodies, organizations, and staying up to date on the current RWD landscape in Europe What We’re Looking For: 10+ years of industry experience (CRO/Pharma/Data Vendor) with the ability to demonstrate the following: - In depth understanding of the clinical research process and business, medicines and medical device development, healthcare market and related sectors - Broad cross-functional experience in the healthcare, scientific and real-world data environment - Experience with major patient data models (e.g. CDISC, OMOP, LOINC, FHIR, MEDra, SnoMED etc.) - Demonstrated ability to apply scientific or real-world data solutions to address clinical or commercial questions and needs - Experienced in budgets and cost evaluation of RWD based solutions - Understanding of project management principles - Master’s degree in biomedical informatics, public health, data science, life sciences or related field - Advanced degree (or equivalent experience) in biomedical informatics, public health, data science, life sciences or related field desired - Effective translation of strategy into executable plans - Leadership skills in an evolving environment – change management - Excellent oral and written communication skills - Excellent customer focus (internal and external) - Experienced in establishing meaningful external partnerships & collaborations with health systems, vendor companies, and individual contributors within the region - Ability to manage multiple projects and priorities - Ability to identify where regulated requirements apply - Technical skills preparing and processing RWD for application and analysis



