Appeals & Grievances Manager

Detego Health; Omaha (NE); Hybrid; USD 80.000 - 100.000; Vollzeit

Benefits dieser Stelle

401(k) matching

Health insurance

Dental insurance

Vision insurance

Life insurance

Paid time off

Health savings account

Employee assistance program

Zusammenfassung

Detego Health in Omaha seeks an Appeals and Grievances Manager to lead the appeals & grievances function within Compliance. You will oversee intake, tracking, and resolution of appeals, ensure regulatory timelines, and manage a team dedicated to accuracy and audit readiness.

The role emphasizes collaboration with Claims, Legal, Customer Service, and other internal teams to improve processes, with hybrid in-office/work arrangement and a focus on quality and compliance in health plan operations.

Qualifikationen

• Associate degree or equivalent required.
• 3+ years of experience in appeals, grievances, claims administration, compliance, or healthcare operations.
• Experience leading employees, workflows, or operational functions.
• Strong knowledge of documentation requirements, regulatory timelines, and case management practices.

Aufgaben

• Lead, coach, and develop employees responsible for appeals and grievances.
• Oversee intake, assignment, review, tracking, and resolution of member and provider appeals and grievances.
• Ensure cases are processed within applicable state, federal, contractual, and organizational timelines.
• Review complex, high-risk, or time-sensitive cases and coordinate escalation and resolution.
• Prepare leadership reports and support regulatory or client audits.

Kenntnisse

Team leadership

Performance metrics

Regulatory knowledge

Communication

Problem solving

Ausbildung

Associate degree or equivalent

Jobbeschreibung

Company OverviewDetego Health's mission is to connect real-life needs with innovative product design, delivering affordable, approachable health care benefits that feel personal, while deeply understanding our members and partners to improve lives and redefine access to health care.We're looking for passionate people who want to make a difference and help us redefine access to health care for individuals and small businesses by delivering certainty, connection and significance where others won’t.Ready to build something great together? Join a team that values growth, collaboration and the unique perspective you bring.Position SummaryThe Appeals and Grievances Manager leads the appeals and grievances function within the Compliance department of the Office of Enterprise Risk, Compliance & Security at Detego Health. This role is responsible for team performance, regulatory compliance, operational quality, and the timely resolution of member and provider appeals and grievances. The manager establishes clear expectations, monitors key performance indicators, manages workloads and escalations, develops staff, and ensures that all cases meet applicable timelines, documentation standards, and regulatory requirements.Key ResponsibilitiesTeam Leadership and Development:• Lead, coach, and develop employees responsible for appeals and grievances.• Establish performance expectations, assign work, and balance team workloads.• Conduct regular one on one meetings with direct reports and document coaching, development needs, and follow-up actions.• Plan and lead recurring team meetings to review priorities, performance, process updates, and compliance requirements.• Provide timely feedback, recognize strong performance, address performance concerns, and support employee development.• Coordinate training and maintain team readiness for new or revised requirements.Operational and Compliance Oversight:• Oversee the intake, assignment, review, tracking, and resolution of member and provider appeals and grievances.• Ensure cases are processed accurately and within applicable state, federal, contractual, and organizational timelines.• Review complex, high-risk, or time-sensitive cases and coordinate appropriate escalation and resolution.• Maintain complete, organized, and audit-ready case documentation.• Support internal and external audits and respond to requests for appeals and grievance records.• Ensure determination letters and other communications are accurate, clear, and compliant.Performance Management and Reporting:• Establish, track, and report key performance indicators, including case volume, turnaround time, timeliness, quality, inventory, aging, and error trends.• Review individual and team performance results and implement corrective actions when targets are not met.• Prepare routine operational and compliance reports for leadership.• Use performance data to identify staffing needs, training opportunities, process gaps, and emerging risks.• Conduct quality reviews to confirm adherence to policies, procedures, and regulatory requirements.Communication and Continuous Improvement:• Collaborate with Claims, Clinical, Legal, Compliance, Customer Service, and other internal teams to resolve cases and address systemic issues.• Communicate professionally with members, providers, clients, and internal stakeholders.• Identify and implement process improvements that reduce turnaround times, improve quality, and strengthen controls.• Develop and maintain standardized workflows, procedures, job aids, and quality controls.• Monitor regulatory and operational changes and communicate their impact to the team.Qualifications• Associate degree or equivalent combination of education and relevant experience• Three or more years of experience in appeals, grievances, claims administration, compliance, or healthcare operations• One or more years of experience leading employees, workflows, or operational functions• Experience tracking performance metrics and managing work to established service standards• Strong knowledge of documentation requirements, regulatory timelines, and case management practices• Strong written communication, organization, problem-solving, and decision-making skills• Experience in health insurance or third-party administrator environments• Familiarity with state and federal requirements governing appeals and grievances• Experience preparing leadership reports and supporting regulatory or client auditsCompensation & BenefitsCompensation: 80,000-100,000Work Location: Omaha-based employees will work in-office or on a hybrid schedule.Benefits: 401(k), 401(k) matching, Dental insurance, Employee assistance program, Health insurance, Health savings account, Life insurance, Paid time off, Vision insuranceDetego Health is an equal opportunity employer