Appeals and Grievances Manager

Job Summary

Managing the operational and regulatory functions of appeals and grievances, the full-time remote Appeals and Grievances Manager will oversee daily case assignments, supervise staff, ensure compliance with regulations, and drive improvements in participant experience and operational effectiveness.

Key responsibilities:

• Leads daily operations of the appeals and grievances department, ensuring timely and accurate case management
• Supervises and develops A&G staff, providing performance expectations and professional development support
• Aggregates and analyzes data to identify trends and opportunities for quality improvement in grievance and appeal processes

Required qualifications:

• Bachelor's degree in health care administration, nursing, public health, business, social work, or a related field required
• Minimum of 3 years of experience in appeals, grievances, or related managed care functions, including supervisory experience
• Knowledge of CMS and state requirements governing participant rights and grievances
• Proficiency with Microsoft Office, especially Excel, Word, and PowerPoint
• Experience working in a regulated health plan environment, such as PACE, Medicare, or Medicaid, preferred