Supervisor, Appeals and Grievances

L.A. Care Health Plan; 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

Volunteer Time Off (VTO)

Job summary

L.A. Care Health Plan is seeking a Supervisor for Appeals and Grievances to lead the intake, research, and resolution of all appeals and grievances.

The role involves directing the team to ensure timely investigations and compliance with company policies and procedures, with escalation handling as needed. The position requires a Bachelor's Degree, 2+ years in supervisory roles, and 3+ years in healthcare settings related to grievances, appeals, or claims.

Qualifications

• Bachelor's Degree required; Master’s preferred.
• Experience in healthcare grievance/appeals or related regulatory areas is desirable.
• Leadership experience in supervising teams and operations.

Responsibilities

• Supervise Appeals and Grievances team and operations.
• Monitor KPIs, SLAs, and performance scorecards for regulatory compliance.
• Collaborate with internal departments to resolve escalated cases.
• Develop and maintain policies, workflows, and training for the team.
• Prepare audits and recommend corrective actions based on regulatory findings.

Skills

Data management

Regulatory knowledge

Communication skills

Project management

Staff leadership

Microsoft Office

Problem solving

Education

Bachelor's Degree

Master's Degree

Tools

Microsoft Office

Visio

Excel

Word

Job description

Salary Range: $77,265.00 (Min.) - $100,445.00 (Mid.) - $123,625.00 (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents.

We are the nation’s largest publicly operated health plan.

Serving more than 2 million members, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Supervisor, Appeals and Grievances is responsible for direct supervision and support of the team responsible for the intake, research, resolution, tracking, trending and reporting within the Appeals and Grievances department. This position will be accountable for leading and directing the work for the Appeals and Grievances department by monitoring the research, negotiation and resolution of all types of appeals and grievances to ensure thorough investigations are completed as outlined in the company policies and procedures. Provides support and ownership of cases identified as escalated, complex and/or multi-issue appeals and grievances on an as needed basis. Collaborates with internal departments to ensure timely resolution. This position will be responsible for analyzing and trending for all appeals and grievances. Responsible for the development and maintenance of the appeal and grievance Policies and Procedures (P&Ps), workflows, Member correspondence, and training as needed, or on an annual basis. The position supervises all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Responsible for supervising daily operations that includes setting goals, evaluating performance and addressing issues. Ensure the team's efforts align with organizational goals and objectives.

Duties

• Evaluate daily reports to ensure individual and team Key Performance Indicators (KPIs), Service Level Agreements (SLAs), Performance Scorecards meet regulatory requirements.
• Provide direction to staff for complex/sensitive member and provider inquiries, concerns, complaints, appeals, and grievances. Conduct weekly 1:1s with direct reports.
• 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, but not limited to monitoring day-to-day activities of staff, monitoring of staff performance, mentoring, training, and cross-training of staff, handling of questions or issues, etc. raised by staff, encourage staff to provide recommendations for relevant process and systems enhancements, among others.
• Responsible for creating the schedules for assigned staff. Provide ongoing development opportunities for their assigned staff.
• Assist and recommend in the establishment of performance goals, communicating to the assigned staff. Ensure team complies with organizational and regulatory standards.
• Responsible for addressing issues, resolving disputes, and ensuring compliance with policies and procedures.
• Responsible for allocating resources effectively and ensuring optimal utilization.
• Responsible for administrative work, including reporting, budgeting, and policy implementation.
• Perform other duties as assigned.

Education Required

Bachelor's Degree

In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Master's Degree

Experience

Required:

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.

Preferred

Previous experience in Managed Health, preferably in Customer Service, Appeals and Grievances and/or Claims.

Skills

Required:

• Ability to manage and organize large volumes of data.
• Knowledge of regulatory and accreditation entities and their requirements.
• Excellent verbal and written communication skills and interpersonal skills.
• Good working knowledge of licensure and regulatory requirements, and accreditation standards.
• Ability to work independently.
• Ability to solve complex issues and identify creative solutions.
• Computer ease and literacy with Microsoft Office (Word, Excel, Power Point, Access, and Visio).
• Skilled in leading, mentoring, and developing staff.
• Proficient in overseeing operations and managing resources.
• Ability to plan and make decisions that align with organizational goals.
• Skilled in handling paperwork, budgets, and reports.
• Strong motivational skills.

Physical Requirements

Light

Additional Information

This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.

This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned

Salary Range Disclaimer:

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care Offers a Wide Range Of Benefits Including

• Paid Time Off (PTO)
• Tuition Reimbursement
• Retirement Plans
• Medical, Dental and Vision
• Wellness Program
• Volunteer Time Off (VTO)