Director, Grievance and Appeals(Preferred Experience In Managed Care)

CareSource Management Services LLC; Dayton (OH); Hybrid; USD 113,000 - 198,000; Full time

Job summary

CareSource is seeking a Director of Grievance and Appeals to lead the oversight of appeals and grievance processes within a healthcare operations setting. The role emphasizes execution, outcomes, continual improvement, and performance enhancement across the department.

The ideal candidate will have senior management experience in managed care, a strong background in regulatory compliance, budgeting, and cross-functional collaboration with internal partners and legal counsel.

Qualifications

• Bachelor degree or equivalent required; healthcare experience preferred.
• Minimum 5 years of management experience in care/gov health admin.
• Experience overseeing grievance and appeals processes is preferred to align with director level responsibilities.
• Knowledge of regulatory compliance and risk management is essential.
• Strong leadership, budgeting, and cross-functional collaboration are required.

Responsibilities

• Oversee the grievances and appeals processes to ensure effective operation.
• Direct and manage the grievance/appeals department with focus on outcomes and improvement.
• Design and implement processes, policies, trainings to ensure regulatory compliance.
• Identify performance gaps and implement corrective actions.
• Analyze data to identify improvements and present to Operations leadership.
• Coordinate with plan attorneys on litigated cases and support case preparation.

Skills

Leadership

Operations management

Regulatory compliance

Data analysis

Budgeting

Stakeholder management

Communication skills

Healthcare industry experience

Education

Bachelor of Science/Arts or equivalent

Master’s degree preferred

5+ years of management experience

Managed care experience

Leadership in Healthcare G&A

Job description

Job Summary

The Director, Grievance and Appeals is responsible for oversight of appeals and grievance processes. Directing and ensuring the efficient operational management of appeals and grievance department/ function with emphasis on execution, outcomes, continual improvement and performance enhancement.

Essential Functions

• Responsible for oversight of appeals and grievance processes.


• Directs and ensures the efficient operational management of appeals and grievance department/ function with emphasis on execution, outcomes, continual improvement and performance enhancement.


• Designs and implements processes, policies, trainings and procedures to ensure compliance with new and existing regulations.


• Addresses areas of below-standard performance and implements mechanisms to bring performance up to standard.


• Tracks and trends preventable appeals and grievances and presents findings to Operations leadership.


• Minimizes legal and financial risk by taking appropriate measures to protect the interest of members and providers.


• Identifies need for in-house legal involvement on sensitive cases, and coordinates with plan attorneys on litigated cases, helping to oversee case preparation and research.


• Provides fiscal management and support including developing operation budgets and completing forecasts and variance reporting.


• Ensures appropriate systems and technology are in place to meet compliance, quality and operational efficiency measures for the department/ function.


• Analyze data regularly to identify and implement process improvements.


• Coordinates grievance/appeal committee meeting with appropriate parties.


• Establishes and maintains cohesive relationships with internal partners.


• Perform any other job duties as requested.

Education and Experience

Bachelor of Science/Arts (BA/BS) or equivalent years of work experience is required

Master’s degree is preferred

Minimum of five (5) years of management experience is required

Managed care experience is required

Direct leadership experience in a Healthcare operational G&A environment is required

Senior management experience is preferred

Competencies, Knowledge and Skills

• Customer service skills with the ability to interact professionally and effectively with members, providers, internal business areas and colleagues


• Strong analytical skills with the ability to create reports and interpret operational, utilization and financial data


• Proven problem-solving skills with the ability to look for root causes and develop implementable, workable solutions


• Computer proficiency with knowledge and experience in a Windows environment


• Maintain regulatory knowledge for compliance


• Customer service orientation


• Strong written and verbal communication skills


• Ability to work in a fast paced environment


• Decision making and problem solving skills

Licensure and Certification

None

Working Conditions

General office environment; may be required to sit or stand for extended periods of time

Compensation Range

$113,000.00 - $197,700.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type

Salary

Organization Level Competencies

• Fostering a Collaborative Workplace Culture


• Cultivate Partnerships


• Develop Self and Others


• Drive Execution


• Influence Others


• Pursue Personal Excellence


• Understand the Business

Company Culture

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

#LI-SW2 Brand=CareSource The CareSource mission is known as our heartbeat. Just as we support our members to be the best version of themselves, our employees are driven by our mission to create a better world for members, stakeholders and providers. We are difference-makers who combine compassionate hearts with our unique business expertise to make every opportunity count. Each claim, each phone call, each consumer-centric decision is a chance to change the world for one member, and our employees look for ways to do that every day. The challenge is, there is no one right way to be the difference and we’re looking for people like you that will rewrite that definition every day. We do what it takes to form creative solutions that make our community and the world just a little better. Discover what it means to be #UniquelyCareSource.