Grievance and Appeals Manager
About The Position
Our Grievance and Appeals Manager ensures the team operates efficiently, accurately, and in compliance with all regulatory requirements regarding all grievance and appeals processes. They oversee the management of escalated or high-profile cases, support audits and reporting, drive process improvements, and hold the position of Chairperson of the Grievance and Appeals Committee. This Grievance and Appeals Manager is accountable to maintain knowledge of industry trends, best practices, and protocols. They are accountable to build and maintain partnerships with business areas across and outside of operations to improve communication and responsiveness to the handling of member and provider appeals.
Requirements
- Bachelor’s degree in Business or Healthcare Administration or related field with coursework in insurance and medical terminology; or equivalent post high school education and/or work-related experience.
- 7 or more years of health plan operations experience such as grievance and appeals, call center, claims, utilization management, pharmacy, or provider services.
- 3 or more years in a senior level individual contributor or managerial role.
- Knowledge of federal and state grievance and appeal regulations, including CMS requirements.
- Strong knowledge and understanding of grievance and appeals, call center, claims, utilization management, pharmacy, or provider services.
- Excellent operational and organizational skills with the ability to manage multiple priorities including: Strong analytical, problem-solving, and decision-making abilities.
- Excellent verbal and written communication skills with proven ability to communicate effectively at all levels.
- Demonstrated ability to collaborate across teams to produce results.
- Ability to handle complex, regulated work in a fast-paced environment.
- Ability to manage escalated and sensitive issues with professionalism.
- High speed cable or fiber internet connection.
- Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection.
Nice To Haves
- 5 or more years in a senior level individual contributor or managerial role in Grievance and Appeals.
- Health insurance background in Point of Service (POS), Preferred Provider Organization (PPO), or Medicare Supplement) plans.
Responsibilities
- Manage department operations, ensuring cases are processed accurately and within required timeframes.
- Provide leadership, guidance, and support to specialists through one-on-one coaching, team meetings, and ongoing development.
- Monitor and ensure compliance with all applicable regulatory and accreditation standards, including CMS, URAC, federal and state requirements.
- Support audits and regulatory reviews by preparing required reports and documentation.
- Track grievance and appeals trends to identify opportunities for process and performance improvements.
- Provide guidance and support to staff on escalated, complex, or high visibility cases.
- Collaborate with regulatory, clinical, and cross-functional teams to address issues and enhance processes.
Benefits
- Remote and hybrid work options available
- Performance bonus and/or merit increase opportunities
- 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
- Competitive paid time off
- Health insurance, dental insurance, and telehealth services start DAY 1
- Professional and Leadership Development Programs
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What This Job Offers
Job Type
Full-time
Career Level
Senior
