Sr Manager, Grievance & Appeals Resolution Services; Sr. Manager II

Sr Manager, Grievance & Appeals Resolution Services (Sr. Manager II)

Cal Optima

Join us in this opportunity to lead the Grievance & Appeals Resolution Services (GARS) department. The Sr Manager II will provide oversight and leadership to GARS, ensuring compliance with state and federal regulations and contract requirements, and collaborating with providers, community partners and stakeholders to advance member health with dignity.

• 50% - Leadership Function
• Cultivates and promotes a mission-driven culture of high-quality performance with a member focus on customer service, consistency, dignity and accountability.
• Directs and assists the team in department responsibilities; collaborates with the leadership team to support short- and long-term goals.
• Hires, manages, trains, supports, develops and evaluates direct reports.
• Directs work assignments, measures results and initiates personnel actions.
• Oversees staff assignments to ensure effective allocation of resources and compliance with regulations; establishes production standards.
• Assists the director on key initiatives, special reviews, departmental initiatives and strategic planning.
• Assists leadership in managing critical business risks by promoting process improvement and monitoring remediation activities.
• Collaborates with Cal Optima Health staff and external contacts with regulatory agencies, health networks, community-based organizations and medical groups.
• Leads, coordinates, and monitors policy and procedural changes; maintains revision and implementation processes to support plan regulatory compliance.
• Co-leads Grievance and Appeals quarterly committee meetings; attends internal committees to report activities and trends.
• Maintains knowledge of regulatory requirements (DHCS, CMS, DMHC, NCQA) relevant to grievance and appeals.
• Participates in state and federal regulatory audits as the business lead for grievances and appeals.

• 45% - Program Oversight
• Ensures regulatory protocols and rules for the grievance and appeals process are followed.
• Manages and leads operational and other non-compliance audits.
• Collaborates across GARS to improve processes and address training needs based on audits.
• Acts as a trusted advisor by fostering strong relationships with internal and external partners.
• Reviews and analyzes member/provider appeals and grievances to improve root causes and implement action plans.
• Designs resource and capacity management strategies to maximize efficiencies in handling grievances and audits.
• Leads the development of a grievance and appeals training program.
• Proactively communicates with leadership regarding process improvements, project status, risks and issues.
• Performs audits and oversight to ensure policy compliance and operational efficiency.

• 5% - Completes other projects and duties as assigned.

• Bachelor's degree PLUS 5 years of healthcare grievance and appeals experience in a managed care organization; equivalent combination of education and experience may qualify.
• 4 years of leadership experience in a healthcare company.
• Previous state or federal healthcare audit experience.

• Experience with HMO, Medi-Cal/Medicaid, Medicare and/ or other government/public sector experience.
• Current, unrestricted Licensed Vocational Nurse (LVN) or Registered Nurse (RN) license in California.

• Develop rapport and maintain effective working relationships with leadership, staff and external contacts.
• Work independently with sound judgment; excellent written and verbal communication.
• Flexible schedule; availability for evening and weekend events.
• Strong organization, analytical, problem-solving and project management skills.
• Ability to work in a fast-paced environment and manage multiple projects.
• Motivate and lead multi-program teams and external committees/coalitions.
• Proficiency with Microsoft Office and job-specific software.

• Visual reading of screens and printed materials; clear spoken communication; hearing for verbal communication.
• Manual dexterity for typing and writing; ability to stand, bend, crouch, walk, kneel and sit for extended periods.
• Lifting/moving objects up to 25 pounds.

• Competitive compensation for this role.
• Pay range: 317 - $132,969 - $212,751 ($63.93 - $102.2841).
• Final salary based on education, experience and internal equity.
• Partial Telework (telework eligible in California); if telework, must be in California and come to the main office in Orange, CA at least two days per week.
• Benefits information and more at: https://(Use the "Apply for this Job" box below).#benefits
• CalPERS pension program and additional retirement packages.
• Comprehensive benefits and wellness programs, tuition reimbursement, professional and career development opportunities, flexible scheduling, and more.

Locations include building or remote work; typical indoor, sedentary work with travel as needed. Climate and…