Appeals & Grievance Case Resolution Team Lead

Appeals & Grievance Case Resolution Team Lead Location Remote, United States Primary Job Function Operations *
* 44033

Your career starts now. We’re looking for the next generation of health care leaders.

At Ameri Health 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. Ameri Health 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, Ameri Health 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.

The Appeals & Grievance Case Resolution Team Lead provides daily operational leadership and subject matter guidance for a team of Appeals & Grievance Specialists and Administrators. The Team Lead ensures case assignments are handled accurately, timely, and in compliance with all regulatory and organizational requirements. The Team Lead balances individual case management responsibilities with oversight of team performance, quality assurance, and workflow distribution.

Acting as a liaison between staff and management, the Team Leader helps drive operational excellence, fosters Associate development, and supports consistent, high‑quality member experience.

• Lead a team of Administrators and Specialists responsible for processing appeals and grievances.
• Monitor daily work queues, assigning cases based on workload, complexity, and priority.
• Provide technical and procedural guidance to team members to ensure compliance and consistency.
• Review case documentation and correspondence to ensure regulatory accuracy and completeness.
• Act as the first point of escalation for staff regarding case complexity or workflow challenges.

• Ensure department service levels, quality metrics, and turnaround times are consistently met.
• Track and report daily productivity and case completion data to the Supervisor.
• Assist in developing and maintaining standard operating procedures (SOPs) and workflow documentation.
• Identify trends in case submission, errors, or delays, and propose solutions to improve performance.
• Coach and mentor new and existing team members on best practices in case resolution, documentation, and communication.
• Deliver ongoing feedback, performance guidance, and informal training sessions.
• Support onboarding and cross‑training initiatives to strengthen overall departmental resilience.

• Conduct random quality checks and case audits to ensure accuracy and compliance with CMS, NCQA, URAC, and state regulations.
• Assist with audit preparation and documentation collection during internal and external reviews.
• Work collaboratively with internal teams such as Claims, Utilization Management, Regulatory Affairs, and Member Services to facilitate case resolution.
• Participate in process improvement projects and system enhancement discussions.
• Communicate updates and procedural changes from leadership to staff promptly.

• High School/GED.
• Associate’s Degree (Knowledge equivalent to an Associate’s Degree in Health Administration, Business, or related field).
• Preferred 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.
• 1or more years leadership, mentoring, or quality review experience.
• 5 or more years experience in healthcare operations, managed care, compliance, or grievance/appeals coordination. Demonstrated experience handling complex or escalated cases within a managed care organization.

• Proficiency in Microsoft Office Suite (Word, Excel, Outlook, etc.).
• Demonstrated knowledge of CMS, NCQA, URAC, and state‑specific appeals and grievance requirements.
• Strong analytical, investigative, and documentation abilities.
• Ability to manage multiple priorities with accuracy under pressure.
• Strong analytical and problem‑solving abilities.
• Customer service mindset and professional demeanor.

Flexible 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.