Grievance & Appeals Program Manager

Santa Clara Family Health Plan; San Jose (CA); On-site; USD 120,000 - 170,000; Full time

Job summary

Santa Clara Family Health Plan in California seeks a Manager, Grievance & Appeals to lead the development and management of the grievance and appeals processes, ensuring compliant, timely handling for members and providers.

This role oversees staff, interfaces with regulators and providers, analyzes case trends, and drives improvements in customer experience and operational performance.

Qualifications

• Four-year degree in a relevant field and healthcare operations experience.
• Experience leading a grievance/appeals function or similar department.
• Knowledge of Medicare/Medicaid requirements and regulatory guidelines.
• Proven ability to develop and improve cross-functional processes.

Responsibilities

• Read, interpret and implement regulatory guidance for appeals/grievances.
• Lead processes, policies, and workflows to ensure compliant handling.
• Manage reports, audits and case narratives for hearings and reviews.
• Act as SME and contact for escalated grievance & appeals cases.
• Coordinate cross-functional meetings and communicate findings.

Skills

Regulatory knowledge

Leadership

Communication

Time management

Documentation

Stakeholder relations

Attention to detail

Customer service

Education

Bachelor's degree (Business/Health)

Tools

Excel

Outlook

Word

Job description

Santa Clara Family Health Plan in California seeks a Manager, Grievance & Appeals to lead the development and management of the grievance and appeals processes, ensuring compliant, timely handling for members and providers.

This role oversees staff, interfaces with regulators and providers, analyzes case trends, and drives improvements in customer experience and operational performance.