Director, Grievances & Appeals Operations

CareSource; 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

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.