Lead, Appeals & Grievances Operations

L.A. Care; Los Angeles (CA); Hybrid; USD 77,000 - 124,000; Full time

Benefits offered by this job

Paid Time Off (PTO)

Tuition Reimbursement

Retirement Plans

Medical, Dental and Vision

Wellness Program

Job summary

L.A. Care Health Plan in Los Angeles, CA is seeking a Supervisor for Appeals and Grievances to lead the intake, research, resolution, and reporting of complex appeals. You will guide a team, ensure timely investigations, and collaborate with internal departments to meet regulatory standards.

The role requires healthcare grievances/appeals experience and supervisory skills, with a hybrid work schedule and responsibilities in policy, training, and performance management.

Qualifications

• At least 3 years in a healthcare setting in Grievances and Appeals, Compliance, Claims or Call Center.
• At least 2 years of leading process, program, or staff or supervisory experience.
• Equivalency: Completion of the L.A. Care Management Certificate Training Program may substitute for the supervisory/management experience requirement.
• Previous experience in Managed Health, preferably in Customer Service, Appeals and Grievances and/or Claims.

Responsibilities

• Evaluate daily reports to ensure individual and team KPIs, SLAs, and scorecards meet regulatory requirements.
• Provide direction to staff for complex/sensitive member and provider inquiries, concerns, complaints, appeals, and grievances.
• Build and maintain strong working relationships with internal departments involved in appeal and grievance resolution.
• Develop, maintain and implement P&Ps, workflow and training.
• Audit preparation and providing recommendations for Corrective Action Plans from state regulatory agencies.
• Supervise staff, including monitoring day-to-day activities, performance, mentoring, training, and cross-training of staff.
• Create schedules for assigned staff and provide development opportunities.
• Assist and establish performance goals, ensuring team compliance with standards.
• Allocate resources effectively and manage budgets.
• Administrative work, including reporting, budgeting, and policy implementation.
• Perform other duties as assigned.

Skills

Data management

Regulatory knowledge

Communication skills

Licensure requirements

Independent work

Problem solving

MS Office

Staff leadership

Operations management

Budgeting & reporting

Motivation skills

Education

Bachelor's Degree

Master's Degree

Tools

Microsoft Office

Job description

L.A. Care Health Plan in Los Angeles, CA is seeking a Supervisor for Appeals and Grievances to lead the intake, research, resolution, and reporting of complex appeals. You will guide a team, ensure timely investigations, and collaborate with internal departments to meet regulatory standards.

The role requires healthcare grievances/appeals experience and supervisory skills, with a hybrid work schedule and responsibilities in policy, training, and performance management.