Grievance and Appeals Regulatory Oversight Manager

Neighborhood Health Plan of Rhode Island•Smithfield, RI

9d•Onsite

About The Position

The Grievance and Appeals Regulatory Oversight Manager provides strategic and operational oversight of regulatory requirements, compliance, and reporting for grievance and appeals across Medicare, Medicaid, Exchange, and other applicable lines of business. Working collaboratively with the Senior Manager of Grievance and Appeals and the Director of Quality Management and Grievance and Appeals, this role promotes compliance with federal, state, accreditation, and contractual requirements through monitoring, auditing, reporting, and policy management. The manager evaluates operational performance, identifies compliance risks and improvement opportunities, develops corrective actions, and supports regulatory readiness and operational excellence. The role serves as a grievance and appeals regulatory subject matter expert; supports audits and regulatory reviews, including delegated functions; oversees reporting and documentation; and assists with implementing regulatory changes. It monitors and interprets emerging requirements, develops operational guidance, and helps ensure grievance and appeals business processes remain compliant with evolving state and federal regulations. The position is based in Smithfield, Rhode Island, and is listed as full-time with a daytime shift and occasional travel.

Requirements

Bachelor's degree in Healthcare Administration, Public Health, Nursing, or a related field.
At least 5 years of experience in healthcare regulatory compliance, grievance and appeals, or managed care operations.
Demonstrated experience with Medicare, Medicaid/EOHHS, and NCQA regulatory requirements.
Expertise interpreting and operationalizing contractual and regulatory requirements, including identifying and mitigating associated risks.
Experience supporting regulatory compliance and audits, and oversight experience with CMS, EOHHS, NCQA, and other regulatory agencies.
Experience managing vendor/FDR oversight programs and corrective action plans.
Strong analytical and problem-solving skills, including the ability to identify trends and implement corrective actions.
Strong written and verbal communication skills, including presentation and facilitation abilities.
Ability to manage multiple priorities and work independently in a fast-paced, highly regulated environment.
Proficiency in Microsoft Office Suite, including Excel, Word, Outlook, and PowerPoint.

Nice To Haves

Master's degree.
Experience with Medicare Advantage, Medicaid, Exchange, and Dual Eligible Special Needs Plans (DSNPs) programs.
Experience with CMS program audits and reporting requirements.
Experience developing and maintaining operational, clinical, and administrative policies and procedures.
Clinical background or RN licensure.

Responsibilities

Lead and support regulatory oversight activities for grievance and appeals.
Monitor and ensure compliance with CMS, EOHHS, NCQA, state regulatory agencies, and contractual requirements.
Develop, implement, and maintain policies, procedures, monitoring activities, and internal controls to support ongoing compliance.
Interpret evolving regulatory requirements and communicate operational impacts and recommendations to leadership.
Support implementation of regulatory changes and ensure timely operational readiness.
Lead internal monitoring, auditing, and compliance validation activities.
Coordinate and support internal and external audits, regulatory reviews, accreditation surveys, and government examinations.
Develop, implement, and monitor corrective action plans through resolution.
Evaluate operational processes and outcomes to identify opportunities for process improvement, efficiency, and risk reduction.
Analyze grievance, appeal, overturn, timeliness, and complaint trends; identify root causes and recommend corrective actions.
Oversee regulatory reporting and ensure required reports are accurate, complete, and submitted on time.
Develop reporting methodologies, dashboards, and performance metrics to monitor operational and regulatory performance.
Use data analytics to identify trends, operational risks, quality concerns, and compliance opportunities; present findings and recommendations to leadership.
Lead development, review, implementation, and maintenance of departmental policies, procedures, desktop procedures, and regulatory guidance documents.
Ensure policies are operationally effective, compliant with applicable regulations, and aligned with organizational strategies.
Collaborate with business partners to maintain accurate, current regulatory and operational documentation.
Participate in cross-functional projects and support departmental projects, strategic initiatives, and regulatory implementations.
Serve as a regulatory resource and subject matter expert for internal business partners.
Maintain compliance with the organization's Corporate Compliance Program, Standards of Business Conduct, applicable laws and regulations, and departmental policies and procedures.
Exercise due diligence in identifying, preventing, and reporting compliance risks, unethical conduct, fraud, waste, abuse, and other regulatory concerns.
Serve as the business lead for assigned First Tier, Downstream, and Related Entities (FDRs).
Develop and maintain an oversight program for delegated grievance and appeal activities.
Monitor delegated functions, including appeals and grievances, First Call Resolutions, timely grievance referrals, member and provider communications, website and portal content, letter template compliance, and regulatory submissions and reporting.
Conduct operational reviews, performance evaluations, and compliance assessments of delegated entities.
Ensure vendors comply with applicable regulations, contractual obligations, and organizational standards.
Perform other duties and special projects as assigned.