Grievance & Appeals Operations Manager

SCFHP South County Resident Advisory Group; San Jose (CA); On-site; USD 134,000 - 207,000; Full time

Job summary

SCFHP South County Resident Advisory Group is seeking a Manager, Grievance & Appeals in San Jose, CA. You will lead the development and management of all grievance and appeal activities, ensuring compliant processes and a positive member/provider experience.

You will interpret regulatory guidance, oversee staff operations, prepare case files for hearings, and act as the subject matter expert for complex cases. Strong leadership and regulatory knowledge are essential.

Qualifications

• Four-year degree in General Business, Law, Social Sciences or Health Care Administration (R)
• Minimum two years management experience including direct supervisory experience (R)
• Minimum three years of health plan operations experience (R)
• Two years of experience working in grievances and/or appeals (R)
• Knowledge of Medicare and Medicaid/Medi-Cal requirements (R)
• Strong regulatory and process improvement capabilities (R)
• Excellent communication and leadership skills (R)

Responsibilities

• Read, interpret and implement regulatory guidance related to grievances and appeals.
• Demonstrate understanding of appeals and grievances processes and reporting requirements.
• Establish and document processes, policies, and workflows for compliant handling of appeals and grievances.
• Develop corrective action plans to address non-compliance.
• Manage grievance and appeals reporting for accuracy and timeliness.
• Prepare case files and represent SCFHP in hearings and related proceedings.
• Serve as SME and primary contact for complex cases.
• Schedule and facilitate regular department and cross-functional meetings.
• Lead the Grievance and Appeals Workgroup and identify trends for improvement.
• Manage audits of grievance and appeals and support system enhancements.

Education

Four-year degree in General Business, Law, Social Sciences or Health Care Administration

Job description

SCFHP South County Resident Advisory Group is seeking a Manager, Grievance & Appeals in San Jose, CA. You will lead the development and management of all grievance and appeal activities, ensuring compliant processes and a positive member/provider experience.

You will interpret regulatory guidance, oversee staff operations, prepare case files for hearings, and act as the subject matter expert for complex cases. Strong leadership and regulatory knowledge are essential.