Medicare Grievance & Appeals Leader

CareSource; Ohio; Hybrid; USD 83,000 - 133,000; Full time

Job summary

CareSource is seeking a Manager, Grievance and Appeals to oversee the Grievance, Appeal, IRE/IRO and State Hearing teams. The role requires leading staff, ensuring timely and accurate task completion, and maintaining compliance with regulatory standards in a dynamic healthcare environment.

The position emphasizes data-driven oversight, training development, and cross-department collaboration to improve grievance and appeals processes and performance metrics in a fast-paced setting.

Qualifications

• Bachelor's degree or equivalent years of relevant work experience is required.
• Minimum of three (3) years of management experience is preferred.
• Minimum of four (4) years of grievance and appeals experience is preferred.

Responsibilities

• Provide leadership and direction to staff to ensure the goals and standards of the department and CareSource are successfully achieved.
• Manage staff to ensure timely and accurate completion of tasks and issues are accomplished.
• Oversee and monitor processes to ensure department is meeting all regulatory requirements and accreditation standards.
• Oversee and ensure grievances and appeals are resolved and reported appropriately.
• Oversee, analyze and provide feedback to all areas that submit grievances and appeals.
• Develop, implement and execute grievances and appeals training to business areas as needed.
• Analyze and evaluate operations and identify process improvement.
• Identify irregular trends with grievances and appeals; work with other areas as appropriate to identify root causes and appropriate steps for resolution.
• Monitor trends and regulatory changes for impact to the department.
• Report data to appropriate committees with CareSource.
• Lead initiatives to track and trend grievances and appeals data in order to drive process improvements.
• Develop a culture of accountability and flexibility within the team to support the organizational mission and vision.

Skills

Microsoft Office

Interpersonal skills

Communication skills

Problem solving

Critical thinking

Team leadership

Strategic management

Education

Bachelor's degree or equivalent

Tools

ACD systems

Call Management Systems

Job description

CareSource is seeking a Manager, Grievance and Appeals to oversee the Grievance, Appeal, IRE/IRO and State Hearing teams. The role requires leading staff, ensuring timely and accurate task completion, and maintaining compliance with regulatory standards in a dynamic healthcare environment.

The position emphasizes data-driven oversight, training development, and cross-department collaboration to improve grievance and appeals processes and performance metrics in a fast-paced setting.