Director, Grievances & Appeals - Managed Care (Remote)

CareSource; United States; Remote; USD 113,000 - 198,000; Full time

Job summary

CareSource seeks a Director of Grievance and Appeals to oversee the end-to-end appeals and grievance operations, ensuring compliant processes and outcomes. The role focuses on performance improvement, risk management, and collaboration with plan attorneys on sensitive cases.

The ideal candidate has a strong background in managed care, healthcare administration, and senior leadership, with a track record of policy design, budgeting, and data-driven decision making.

Qualifications

• 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.

Responsibilities

• Oversee and direct the appeals and grievance processes to ensure effective operational management and outcomes.
• Design and implement processes, policies, trainings, and procedures to ensure regulatory compliance.
• Track trends in preventable appeals and grievances and present findings to Operations leadership.
• Coordinate with plan attorneys on litigated cases and oversee case preparation and research.
• Develop operating budgets, forecasts, and variance reporting to support fiscal management.
• Analyze data regularly to identify improvements and ensure alignment with quality metrics and regulatory requirements.

Skills

Management experience

Managed care experience

Healthcare operations

Data analysis

Budgeting

Communication skills

Education

BA/BS or equivalent

Master’s degree preferred

Tools

Windows OS

Job description

CareSource seeks a Director of Grievance and Appeals to oversee the end-to-end appeals and grievance operations, ensuring compliant processes and outcomes. The role focuses on performance improvement, risk management, and collaboration with plan attorneys on sensitive cases.

The ideal candidate has a strong background in managed care, healthcare administration, and senior leadership, with a track record of policy design, budgeting, and data-driven decision making.