Senior Manager, Appeals & Grievances

LA Care Health Plan   •  

Los Angeles, CA

5 - 7 years

Posted 242 days ago

This job is no longer available.

Requisition ID:  464


The Senior Manager, CSC Appeals & Grievance is responsible for the centralized intake, logging and triage process for all member appeal and grievances. The Manager oversees the resolution of member appeals and grievances for all product lines (Medi-Cal, Medi-Cal Direct, Healthy Kids, Medicare, PASC-SEIU and L.A. Care Covered) including State Fair Hearings (SFH) in a manner consistent with regulatory requirements from the Department of Managed Health Care, Department of Health Care Services, Centers for Medicare and Medicaid Services and MRMIB, as well as requirements from the National Committee on Quality Assurance (NCQA) and L. A. Care policies and procedures, ensuring 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 appeal and grievances and SFH in a timely and culturally-appropriate manner. Works with internal committees (i.e., Quality Oversight Committee (QOC), Service Improvement Committee (SIC), etc., to review and analyze appeal and grievance trends and recommends corrective action as necessary . Coordinates, tracks, and trends internal and external appeal and grievance reports and oversee the complaint systems 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.


Associate's Degree

Master's Degree or JD

Bachelor's Degree:  5-7 years of experience resolving healthcare eligibility, access, appeals and grievance issues and a minimum of 3 years of lead, management or supervisory experience. 

AA Degree or 2 years of College: 8 years of experience resolving healthcare eligibility, access, grievance and appeals issues and a minimum of 3 years of lead, management or supervisory experience.

Experience working with firm deadlines, regulators, detailed oriented with the ability to interpret and apply regulations. 
Strong analytical and conflict resolutions skills as well as persuasion skills. 
Proficient in MS Office applications, Word, Excel, Power Point, and Access.

Master's Degree:  3 years of experience resolving healthcare eligibility, access, appeals and grievance issues and a minimum of 3 years of lead, management or supervisory experience. 

Health Plan background a plus along with strong advocacy background