Manager, Appeals and Grievances

L.A. Care Health Plan•Los Angeles, CA

1d•$88,854 - $142,166•Hybrid

About The Position

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members, we make sure our members get the right care at the right place at the right time. Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose. Job SummaryThe Manager, Appeals and Grievances is responsible for the centralized intake, logging and triage process for all member appeals and grievances. The Manager oversees the resolution of member appeals and grievances for all product lines (Medi-Cal, Medi-Cal Direct, Medicare, PASC-SEIU and L.A. Care Covered) in a manner consistent with regulatory requirements from the Department of Managed Health Care, Department of Health Care Services, Centers for Medicare & Medicaid Services, as well as requirements from the National Committee on Quality Assurance (NCQA) and L.A. Care policies and procedures. This position ensures the proper handling of member complaints whether presented by members, their authorized representative, the Ombudsman office, state contractors, member advocates, L.A. Care Board Members, providers, etc. The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member appeals and grievances in a timely and culturally-appropriate manner. Coordinates, tracks, and resolves internal and external appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement. Ensures timely appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal Quality Oversight Committee, etc. Collaborates with internal departments (Member Services, Provider Network Operations, Claims, Utilization Management, Pharmacy, and Quality Management) to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to community partners as appropriate. Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., consistent with regulatory changes. Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Participates and makes recommendations on the department's strategic planning and/or long-term decision-making.

Requirements

Bachelor's Degree
In lieu of degree, equivalent education and/or experience may be considered.
At least 5 years of experience resolving health care eligibility, access, grievance and appeals issues, preferably in health services, legal services and/or public services or public benefits programs.
At least 2 years of leading staff or supervisory/management experience.
Experience working with firm deadlines, regulators, detail oriented with the ability to interpret and apply regulations.
Experience leading teams, projects, initiatives, or cross-functional groups.
Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.
Strong customer service and excellent oral and written communication skills.
Strong advocacy background.
Strong analytical and conflict resolution skills as well as persuasion skills.
Proficient in MS Office applications, Word, Excel, Power Point, and Access.
Strong interpersonal skills for building relationships, fostering teamwork, and creating a positive work environment. Ability to guide and support team members.
Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.
Skilled in mediating disputes and resolving conflicts in a fair and constructive manner. Must have a deep understanding of financial principles.
Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.
Demonstrated ability to make informed decisions.
Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.
Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

Responsibilities

Manage and oversee the handling of member grievances and appeals, for L.A. Care and Plan Partner members as requested. Establishes and oversees processes and all relevant member correspondence for accuracy, clarity, and cultural appropriateness and sensitivity. Review grievance and State Fair Hearing files for compliance with Policies and Procedures and directives. Review and monitor procedures for identifying quality of care issues and work collaboratively with multiple departments (Claims, Provider Network Operations, Utilization Management, Quality Management, Pharmacy) to appropriately address and resolve member grievances. Serve as the Key Contact for State Fair Hearings, internal and external audits, DMHC and DHCS inquiries. Review and monitor procedures for identifying quality of care issues and work collaboratively with multiple departments (Claims, Provider Network Operations, Utilization Management, Pharmacy) to appropriately address and resolve member and provider grievances.
Manage staff, including, but not limited to: monitoring of day to day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.
Manage complex projects, engage and update key stakeholders, develop timelines, lead others to complete deliverables on time and ensure implementation upon approval.
Responsible for reporting, budgeting, and policy implementation.
Work with internal stakeholders to analyze monthly/quarterly grievance reports and PPG and Plan Partner data. Participates in Quality Oversight Committee, Member Service Quality Committee, and QI Improvement Committee and others as necessary.
Work collaboratively with state entities, providers, plans, community advocates, and key stakeholders (member representatives) to address cumbersome administrative issues negatively impacting members' access to care.
Perform other duties as assigned.