Grievance & Appeals Operations Manager

The Job

To oversee and manage the grievance and appeals process, ensuring timely, fair, and compliant resolution of cases while maintaining high standards of customer service and adherence to regulatory requirements.

You Will

• Ensure alignment to and achievement of the organizations goals by managing and overseeing the Grievance and Appeals Department’s day-to-day operations and productivity.
• Ensure completion of required activities for grievance, appeal and complaint functions within the required timeframes by establishing and maintaining effective workflow, systems, tools and monitoring processes and by performing necessary process improvements.
• Ensure staff performance by acting as the first line resource for staff and assisting in problem solving specific issues as well as improving systems and tools, implementing and maintaining proper staffing including use of temporary staff.
• Ensure compliance with and adhere to all regulatory and quality standards including but not limited to : Centers for Medicare and Medicaid Services (CMS), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), and Department of Managed Health Care (DMHC) as it relates to the Grievance and Appeal Department activities by establishing and maintaining processes for understanding, training to, and monitoring adherence to the standards and by preforming necessary process improvements to address areas of identified non-compliance.
• Ensure staff is trained to review incoming inquires for both Medicare Part C and Part D, determine case classification, and prepare cases for review by either the Pharmacist or the Medical Director following SCAN and department policies and procedures to achieve organizational goals and outcomes.
• Ensure environment and culture of teamwork by facilitating staff meetings and interdisciplinary team meetings.
• Ensure that department policies and procedures, desktop procedures, workflows, job aides, and training materials, are current and accurately reflect processes in order to provide consistent quality care and comply with regulatory requirements.
• Partner with stakeholders and department management to create and review department metric reporting for productivity and efficacy to support organizational vision and goals.
• Function as the department subject matter expert and represent department at assigned committees to support two-way communication.
• Interface with HCS Medical Director to ensure quality case review occurs in accordance with department policy and procedures.
• Maintain staff by recruiting, selecting, orienting, and training employees; maintaining a safe and secure work environment; and developing personal growth opportunities.
• Actively support the achievement of SCAN’s Vision and Goals.
• Other duties as assigned.

Your Qualifications

What's in it for you?

Salary : $80 - $128