Grievance and Appeals Operations Manager
2 weeks ago
The Grievance and Appeals Operations Manager is tasked with overseeing and guiding the team responsible for the reception, investigation, resolution, monitoring, analysis, and reporting within the Grievances and Appeals division. This role is pivotal in steering the efforts of the department by ensuring comprehensive investigations are conducted in accordance with established company policies and procedures. The manager will provide assistance and take ownership of cases that are deemed escalated, intricate, or involve multiple issues as necessary. Collaboration with internal teams is essential to guarantee prompt resolutions. This position also entails the analysis and trending of all grievances and appeals.
Key Responsibilities:
- Review daily performance reports to ensure that individual and team Key Performance Indicators (KPIs), Service Level Agreements (SLAs), and Performance Scorecards align with regulatory standards.
- Guide staff in addressing complex and sensitive inquiries from members and providers, including concerns, complaints, appeals, and grievances. Conduct regular one-on-one meetings with direct reports.
- Establish and nurture effective working relationships with internal departments involved in the resolution of grievances and appeals.
- Develop, maintain, and implement Policies and Procedures (P&Ps), workflows, and training programs.
- Prepare for audits and provide recommendations for Corrective Action Plans in response to state regulatory agency findings.
- Supervise team members, which includes monitoring daily activities, assessing staff performance, mentoring, training, and cross-training, as well as addressing questions or issues raised by staff. Encourage team members to propose relevant process and system improvements.
Essential Qualifications:
- A minimum of 3 years of experience in a healthcare environment focusing on Grievances and Appeals, Compliance, Claims, or Call Center operations.
- At least 2 years of experience in a leadership role, managing processes, programs, or staff.
-
Appeals and Grievances Manager
23 hours ago
Los Angeles, California, United States Insight Global Full timeJob SummaryThe Appeals and Grievances Supervisor is responsible for overseeing the Appeals and Grievances department, ensuring thorough investigations are completed according to company policies and procedures. This role involves leading and directing the team's work, monitoring research, negotiation, and resolution of all types of appeals and grievances....
-
Appeals and Grievances Manager
23 hours ago
Los Angeles, California, United States Insight Global Full timeJob SummaryThe Appeals and Grievances Supervisor is responsible for overseeing the Appeals and Grievances department, ensuring thorough investigations are completed according to company policies and procedures. This role involves leading and directing the team's work, monitoring research, negotiation, and resolution of all types of appeals and grievances.Key...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) 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 in five health plans, we make...
-
Appeals and Grievances Specialist
6 days ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Customer Solution Center Appeals and Grievances Specialist II will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment.This position will provide resolution of complaints in compliance with regulatory requirements, including CMS, DHCS, DMHC, MRMIB and NCQA standards.This position...
-
Appeals and Grievances Specialist
6 days ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Customer Solution Center Appeals and Grievances Specialist II will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment.This position will provide resolution of complaints in compliance with regulatory requirements, including CMS, DHCS, DMHC, MRMIB and NCQA standards.This position...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, Max.)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 in five health plans, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, Max.) 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 in five health plans, we make...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $77, Min.) - $100, Mid.) - $123, Max.) 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 in five health plans, we make...
-
Appeals and Grievances Specialist
1 week ago
Los Angeles, California, United States L.A. Care Health Plan Full timeJob SummaryThe Customer Service Representative II plays a critical role in ensuring that member and provider complaints and appeals are resolved in a timely and fair manner. This position requires strong independent judgment, conflict resolution, and persuasion skills to resolve complex issues.Key ResponsibilitiesInvestigate and resolve administrative...
-
Appeals & Grievance Compliance Analyst
1 month ago
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88,854.00 (Min.) - $115,509.00 (Mid.) - $142,166.00 (Max.) 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 in five...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $60, Min.) - $75, Mid.) - $91, Max.) 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...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.)PLEASE NOTE: This position will work Sunday thru Thursday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone.Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) PLEASE NOTE: This position will work Tuesday - Saturday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone. Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
-
Los Angeles, California, United States L.A. Care Health Plan Full timeSalary Range: $88, Min.) - $115, Mid.) - $142, Max.) PLEASE NOTE: This position will work Wednesday - Sunday, 7 a.m. to 4 p.m. PST, with rotating holidays. At this time, we are only considering those candidates that live in the Pacific Time Zone. Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to...
-
Healthcare Claims Operations Manager
2 weeks ago
Los Angeles, California, United States Kaiser Permanente Full timePosition OverviewWe are seeking a dedicated Claims Operations Coordinator III to join our team at Kaiser Permanente. This role is essential in ensuring the smooth processing of health insurance claims.Key ResponsibilitiesManage the adjudication process for health insurance claims, ensuring compliance with regulatory standards.Address and resolve disputes,...
-
Claims Operations Specialist III
2 weeks ago
Los Angeles, California, United States Kaiser Permanente Full timePosition OverviewThe Claims Operations Coordinator III plays a vital role in the management of health insurance claims. This position requires a thorough understanding of claims adjudication processes, including the handling of disputes, appeals, and grievances.Key ResponsibilitiesUtilize knowledge of regulatory guidelines to ensure compliance and interpret...
-
Customer Solution Center Supervisor
6 days ago
Los Angeles, California, United States Insight Global Full timeAbout the RoleThe Appeals and Grievances Supervisor is a key member of the Customer Solution Center team, responsible for overseeing the intake, research, resolution, tracking, trending, and reporting of appeals and grievances within the department.This role involves leading and directing the team's work by monitoring the research, negotiation, and...
-
Regulatory Compliance Analyst II
2 weeks ago
Los Angeles, California, United States Insight Global Full timeJob OverviewThe Regulatory Compliance Analyst II plays a crucial role in ensuring adherence to regulatory requirements by formulating auditing methodologies, overseeing the compliance framework, executing focused audits, and offering suggestions for remedial actions. In this capacity, you will be responsible for developing a corrective action strategy for...
-
Housing Operations Manager
2 weeks ago
Los Angeles, California, United States A COMMUNITY OF FRIENDS Full timeJob OverviewPOSITION SUMMARYUnder the guidance of the Property Supervisor and with the support of the Director of Property Management, the Property Manager is accountable for overseeing the assigned property to ensure operational, financial, and community well-being. This role encompasses the daily management of the supportive housing facility, including...
-
Medical Director, Clinical Leadership Expert
1 week ago
Los Angeles, California, United States UCLA Health Full timeKey Clinical Leadership RoleTake on a pivotal clinical leadership position within a dynamic healthcare organization. Drive the delivery of high-quality, cost-effective care for Medicare Advantage members. Elevate your expertise and contribute to the success of New Century Health Plan.Reporting to the Chief Medical OfficerYou will play a critical role in...
