Supervisor, Appeals and Grievances

L.A. Care Health Plan•Los Angeles, CA

1d•$77,265 - $123,625•Hybrid

About The Position

L.A. Care Health Plan is an independent public agency established in 1997 to provide health coverage to low-income Los Angeles County residents. It serves more than 2 million members and describes itself as the nation’s largest publicly operated health plan. Its mission is to provide access to quality health care for vulnerable and low-income communities and residents in Los Angeles County and to support the safety net required to achieve that purpose. The Supervisor, Appeals and Grievances directly supervises and supports the team responsible for intake, research, resolution, tracking, trending, and reporting in the Appeals and Grievances department. The role leads and directs the department’s work, ensuring thorough investigations of appeals and grievances in accordance with company policies and procedures. The supervisor takes ownership of escalated, complex, or multi-issue cases as needed and collaborates with internal departments to support timely resolution. The position analyzes and trends appeals and grievances and develops and maintains related policies and procedures, workflows, member correspondence, and training. It oversees team operations, including hiring, coaching, training, discipline, motivation, goal-setting, performance evaluation, issue resolution, and resource allocation. The role also supports regulatory audit preparation and recommendations for corrective action plans, and ensures the team’s efforts comply with organizational and regulatory requirements. The position requires work after hours, on weekends and holidays, on-call work, and occasional flexibility in hours or shift during critical situations. The schedule is hybrid remote. The role also requires managing varying caseloads and adapting to changing priorities, including redistributed assignments and team projects.

Requirements

Bachelor's degree; equivalent education and/or experience may be considered in lieu of a degree.
At least 3 years of experience in a healthcare setting in grievances and appeals, compliance, claims, or a call center.
At least 2 years of experience leading a process, program, or staff, or supervisory experience. Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.
Ability to manage and organize large volumes of data.
Knowledge of regulatory and accreditation entities and their requirements.
Excellent verbal and written communication and interpersonal skills.
Good working knowledge of licensure and regulatory requirements and accreditation standards.
Ability to work independently and solve complex issues and identify creative solutions.
Computer literacy and ease with Microsoft Office, including Word, Excel, PowerPoint, Access, and Visio.
Skill in leading, mentoring, and developing staff; overseeing operations and managing resources; planning and making decisions aligned with organizational goals; handling paperwork, budgets, and reports; and motivating staff.
Ability to handle varying caseloads and adapt to changing priorities.
Ability to work after hours, weekends, holidays, and on-call, and to occasionally adjust hours or shift during critical situations.

Nice To Haves

Master's degree.
Previous experience in managed health, preferably in customer service, appeals and grievances, and/or claims.

Responsibilities

Evaluate daily reports to ensure individual and team KPIs, SLAs, and performance scorecards meet regulatory requirements.
Direct staff handling complex or sensitive member and provider inquiries, concerns, complaints, appeals, and grievances; conduct weekly one-on-one meetings with direct reports.
Build and maintain strong working relationships with internal departments involved in appeal and grievance resolution.
Develop, maintain, and implement policies and procedures, workflows, and training.
Prepare for audits and provide recommendations for corrective action plans from state regulatory agencies.
Supervise staff, including monitoring daily activities and performance, mentoring, training and cross-training, addressing staff questions and issues, and encouraging process and systems improvement recommendations.
Create schedules for assigned staff and provide ongoing development opportunities.
Assist with establishing performance goals, communicate those goals to staff, and ensure compliance with organizational and regulatory standards.
Address issues, resolve disputes, and ensure compliance with policies and procedures.
Allocate resources effectively and ensure optimal utilization.
Perform administrative work, including reporting, budgeting, and policy implementation.
Analyze and trend appeals and grievances; take ownership of escalated, complex, or multi-issue cases as needed.
Perform other duties as assigned.