Senior Manager, Clinical Appeals Grievances

Healthfirst; New York (NY); On-site; USD 123,000 - 188,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Incentive programs

Life insurance

401k contributions

Job summary

Healthfirst is seeking a Senior Manager, Clinical Appeals & Grievances in the New York area. The role leads daily operations, partners with cross‑functional leaders, and drives continuous improvement in clinical appeals and grievances processing to ensure timely, compliant outcomes.

The position requires RN or LPN licensure, a bachelor’s degree or equivalent experience, and experience with utilization management or appeals. Strong leadership and vendor management capabilities are essential.

Qualifications

• Bachelor's degree from an accredited institution or equivalent work experience.
• RN or LPN licensure or credentials.
• Experience with utilization management or appeals/grievances processing.
• Understanding healthcare payer operations, regulatory requirements, and compliance implications.
• Proven track record of high performance in a fast-paced, regulated environment.

Responsibilities

• Oversee daily operations, delegate work, and monitor productivity and quality.
• Ensure Appeals and Grievances processes comply with regulatory and organizational requirements.
• Support workforce planning and staffing needs.
• Coach and develop teams to meet performance and operational goals.
• Provide guidance on internal policies and regulatory requirements.
• Standardize workflows and implement best practices to improve production, quality, and efficiency.
• Collaborate with leadership to set departmental goals and review progress monthly.
• Oversee C2C Innovative Solutions, Fair Hearing, and External Appeal processes for timely case management.
• Manage vendor performance and ensure service levels and compliance expectations.
• Build cross-department relationships to drive improvements and resolve issues.
• Analyze trends, identify gaps, and implement corrective actions.
• Prepare and review operational reports to guide decisions.

Job description

The Senior Manager, Clinical Appeals & Grievances provides strategic and operational leadership for the Clinical Appeals & Grievances function, ensuring timely, high-quality, and compliant review of clinical appeals and/or grievance cases. This role oversees day-to-day operations, leads internal teams, and partners with cross-functional leaders to optimize workflows, standardize processes, and drive continuous improvement. As a subject matter expert in Appeals & Grievances, the Senior Manager leverages data, performance metrics, and industry best practices to enhance operational efficiency, ensure regulatory compliance, and support organizational goals for quality, growth, and member satisfaction.

Job Description

• Oversee daily operations, delegate work, and monitor productivity, quality and operational performance
• Ensure Appeals and Grievances processes comply with all regulatory and organizational requirements
• Assess staffing needs and support organizational design and workforce planning initiatives
• Lead, coach, and develop individual contributors and people leaders to achieve performance and operational goals
• Provide guidance on internal policies, procedures, and regulatory requirements.
• Standardize workflows and implement best practices to improve production, quality, compliance, and efficiency
• Partner with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gaps
• Oversee C2C Innovative Solutions, Fair Hearing, and External Appeal processes to ensure timely and complaint case management
• Manage vendor performance and ensure service levels and compliance expectations are achieved
• Build and sustain collaborative relationships across departments to drive operational improvements and resolve process concerns
• Analyze operational trends, identify performance gaps and implement corrective actions
• Prepare and review operational reports and performance metrics to make, guide, and support informed business decisions
• Additional duties as assigned

Minimum Qualifications

• Bachelor's degree from an accredited institution or equivalent work experience
• RN or LPN
• Work experience with utilization management or appeals and grievance processing
• Experience requiring understanding of healthcare payer operations, regulatory requirements, and compliance implications
• Demonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment

Preferred Qualifications

• MBA or master's degree from an accredited institution with focus on business or healthcare administration
• Demonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelines
• Leadership experience in a focus area of operational excellence or audit
• Experience developing strategy and processes for a department or function
• Experience managing vendors as an extension of a core team
• Experience working and/or managing in a virtual environment
• Prior experience leading a team of people leaders

Hiring Range*

• Greater New York City Area (NY, NJ, CT residents): $122,900 - $188,020
• All Other Locations (within approved locations): $105,100 - $160,480

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.