Senior Manager, Clinical Appeals & Grievances — Operations Lead

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

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.