Appeals Grievance Supervisor - Aspire Health

Montage Health

3d•$79,040 - $85,280•Remote

About The Position

The Appeals & Grievances Supervisor is responsible for the day-to-day oversight, direction, and training of staff responsible for researching, documenting, and resolving member complaints, appeals, and grievances across all lines of business, including Medicare Advantage, Commercial HMO, and Self-Funded employer groups. The Supervisor ensures that all cases are processed accurately, compassionately, and within required regulatory and contractual timeframes. This role monitors case quality, ensures compliance with CMS and state guidelines, and oversees the preparation and delivery of clear, member-focused resolution letters. The Supervisor will work in collaboration with the Director of Health Plan Operations to analyze case volumes and trends, prepare regular reports for internal stakeholders and executive leadership, and supports compliance in corrective action development, when required. Additionally, the Supervisor coordinates with Compliance during audits, regulatory reviews, and external inquiries to ensure accurate, timely, and complete submission of all required documentation. The Supervisor maintains and updates all policies, workflows, and training materials related to Appeals and Grievances to ensure that staff remain fully trained and compliant with all applicable CMS, DMHC, and employer group standards.

Requirements

Four (4) years of experience working with Medicare in a managed care environment.
Experience performing grievance and appeals processing at all levels
Participation in CMS/Medicare Audits, both internal and external, as well as the completion of Corrective Action Plans as assigned.
Call center, claims department, and/or other customer service experience.
Strong computer capabilities in Microsoft Office Suite and database software.
Ability to participate in and support the goals, vision and overall direction of a system designed to care for a population of patients across the care continuum.
Ability to communicate effectively and professionally, both verbally and in writing.
Ability to summarize information clearly, thoroughly, and quickly in writing.
Ability to deal with difficult situations while providing quality customer service.
Ability to use sound judgement, identify next steps to be taken, and develop appropriate solutions.
Ability to collaborate with multiple parties to solve problems
Bachelor’s degree or equivalent in a field related to health, business, social sciences, humanities, or other related field.

Nice To Haves

Knowledge of Medicare, Managed Care, and medical terminology preferred
Bachelor's degree in a relevant subject, such as Healthcare Administration preferred.

Responsibilities

Develops and maintains the program description, departmental workflows, tools, service level agreements, policies and procedures, reports, and training materials.
Communicates departmental status, emerging issues, and performance trends to leadership as needed.
Prepares all required Appeals & Grievances (A&G) reports for CMS and other regulatory agencies, ensuring accuracy, completeness, and timely internal review prior to submission.
Provides leadership, training, coaching, and performance evaluation for A&G staff; develops team members and supports the Director in hiring of A & G Staff.
Oversees the organizational grievance training program, ensuring regular training of staff and departments to maintain regulatory compliance.
Works under the lead of the Director of Health Plan Operations to identify trends, address root causes, and support process improvements that impact member and provider experience.
Guides staff in the review, research, routing, and monitoring of complaints, grievances, and appeals to ensure timely, accurate, and fully documented resolutions.
Manages complex or escalated grievances and appeals requiring higher-level review and judgment.
Supports the Compliance department with the timely resolution of CMS Compliance Tracking Module (CTM) cases.
When necessary, reviews and resolves cases directly, ensuring regulatory timeframes, complete documentation, and clear written communication of decisions; coordinates follow-up activities as needed.
Ensures communications to members, providers, and internal teams are accurate, consistent, and member sensitive.
Prepares case summaries for review, documents discussions, and communicates resulting decisions when applicable.
Participates in internal committees and interdisciplinary meetings, providing reports on case activity, trends, and recommendations for improved performance.
Conducts and documents internal audits of A&G operations in accordance with CMS and other regulatory requirements.
Ensures A&G processes and staff comply with all CMS, state, and contractual requirements.
Maintains confidentiality of member and provider information in accordance with Aspire Health policies and all federal and state regulations.
Performs other duties, projects, and responsibilities as assigned.