Supervisor Provider Appeals and Grievances

Responsibilities Leadership and Staff ManagementSupervise daily activities of assigned Appeals & Grievance staff, including scheduling, workload distribution and case prioritizationProvide ongoing coaching, performance feedback, and mentoring to develop Associate competenciesServe as the first line of escalation for complex cases, providing subject matter expertise and decision supportOperational OversightMonitor daily inventory levels, turnaround times, and productivity metrics to ensure operational goals are metReview and approve case documentation and correspondence for completeness, accuracy, and complianceEnsure all appeals and grievance activities adhere to departmental policies, and standard operating procedures (SOPs), and regulatory requirementsAssist in the development and revision of procedures and workflow documentation to improve efficiency and accuracyCompliance & Quality Maintain departmental compliance with all regulatory requirements (CMS, NCQA, URAC, and state specific regulations)Conduct routine case audits and quality reviews; document findings and implement corrective actions Partner with Compliance and Quality departments to prepare for internal and external audits Reporting & CommunicationTrack and report on key operational metrics, including productivity, accuracy, and compliance indicatorsCross-Functional CollaborationCoordinate with Claims, Utilization Management, Member Services, Legal, and Compliance to ensure Consistent resolution of appeals and grievancesEducation and Experience Associate Degree in Health Administration, Business, or related field. Associate Degree in Nursing or Bachelor Degree in Nursing preferredPreferred Experience Level (if different from minimum required): Knowledge of medical terminology, benefit interpretation, and regulatory processes preferred. Prior experience working with CMS, Medicaid, or state-regulated appeals processes preferred.Minimum of 3 years of experience leading a team of clinical and non clinical staffMinimum of 3 years of clinical practice experience as a Registered NurseMinimum of 5 years experience in healthcare operations, managed care, compliance, or grievance/appeals coordinationDemonstrated experience overseeing complex or escalated cases within a managed care organization.LicensureActive and unencumbered Registered Nurse license (preferred)Skills and AbilitiesProven leadership and people management skillsProficiency in Microsoft Office Suite (Word, Excel, Outlook, etc.)Demonstrated knowledge of CMS, NCQA, and state-specific appeals and grievance requirementsStrong analytical, investigative, and documentation abilitiesExcellent written and verbal communicationAbility to manage multiple priorities with accuracy in a fast-pace environmentCustomer service mindset and professional demeanorYour career starts now. We’re looking for the next generation of health care leaders.At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.Discover more about us at .Our Comprehensive Benefits PackageFlexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.