Manager, Grievance & Appeals (Intake)
CalOptimaCalOptima Health is seeking a highly motivated an experienced
Manager, Grievance & Appeals (Intake) to join our team. The Manager, Grievance & Appeals for Intake will manage the day-to-day operations of the Grievance and Appeals Resolution Services (GARS) incoming departmental correspondence. The incumbent will ensure service standards and adherence to regulatory requirements, established policies and procedures regarding the appeals, disputes and grievance process for both members and providers are met. The incumbent may communicate with all levels of internal staff, regulatory agencies, health networks, providers, vendors, community-based organizations and medical groups.
Position Information: - Department: Grievance & Appeals
- Salary Grade: 315 - $109,892 - $175,827 ($52.83 - $84.5322)
- Work Arrangement: Partial Telework
**This position is eligible for telework in California.**
Duties & Responsibilities: - 50% - Leadership
- Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
- Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.
- Hires, trains and develops department staff.
- Manages and makes recommendations on development and maintenance of an effective appeals and grievance process and system consistent with CalOptima Health policy and stated goals, including, but not limited to mechanisms to monitor grievances and appeals involving Department of Managed Healthcare (DMHC), Department of Health Care Services (DHCS), Independent Medical Review, Medi-Cal State Hearings, Office of Administrative Hearings and Appeals, Centers for Medicare and Medicaid (CMS) and external review agencies for CMS.
- Develops, implements, maintains and reviews the adequacy of the CalOptima Health grievance systems, reporting, policies and functions to achieve stated goals, including, but not limited to, grievance resolution and timely responsiveness for all lines of business, provider and member or other stakeholders and applicable accreditation standards to ensure compliance with all relevant regulatory requirements pertaining to GARS.
- Collaborates with the Director of GARS in identifying and analyzing trends and makes recommendations for improvement.
- Creates and implements staff and departmental performance goals.
- 45% - Program Oversight
- Coordinates with the Director of GARS in providing trends to the team and internal and external departments.
- Works with department staff, internal business partners, health networks and outside vendors to coordinate and ensure timely receipt, entry and delivery of all incoming GARS documentation.
- Works with Audit and Oversight and key departments to ensure internal departments and external partners (e.g., health networks and delegates) are up to date with regulatory, departmental and organizational changes impacting the grievance and appeals processes
- Ensures timely and effective data collection, summarization, integration and reporting, including, but not limited to, productivity, status and trend reports for specific committees such as the Quality Improvement Committee, Grievance and Appeals Committee and Quality Assurance Committee of the Board of Directors; completes other ad hoc reporting as required.
- Serves as CalOptima Health's primary point of contact and subject matter expert related to the intake of all disputes, grievances and appeals.
- Assists in the development of policies, procedures and standards for all GARS activities and member or provider processes.
- Participates in DMHC, DHCS and CMS audits related to grievance and appeals for all CalOptima Health programs.
- Assures adequate and timely communication with GARS staff, other CalOptima Health departments and external customers on individual dispute, grievance and appeal issues or trends.
- Stays current on the local, state and federal health care environment, identifying issues that may impact CalOptima Health's programs as it relates to disputes, grievances and appeals.
- Represents the GARS department at various meetings as appropriate.
- Participates in interagency meetings; attends off-site meetings and training sessions.
- 5% - Completes other projects and duties as assigned.
Minimum Qualifications: - Bachelor's degree in a related field required PLUS 3 years of health care management experience in a managed care environment required, preferably in a related area of responsibility (e.g., provider disputes, grievances, appeals); an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
- 2 years of supervisory experience.
Preferred Qualifications: - Health maintenance organization (HMO), Medi-Cal/Medicaid, Medicare and insurance experience or relevant government client or public service experience.
Required Licensure / Certifications: Knowledge & Abilities:
- Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.
- Work independently and exercise sound judgment.
- Communicate clearly and concisely, both orally and in writing.
- Work a flexible schedule; available to participate in evening and weekend events.
- Organize, be analytical, problem-solve and possess project management skills.
- Work in a fast-paced environment and in an efficient manner.
- Manage multiple projects and identify opportunities for internal and external collaboration.
- Motivate and lead multi-program teams and external committees/coalitions.
- Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Physical Requirements (With or Without Accommodations): - Ability to visually read information from computer screens, forms and other printed materials and information.
- Ability to speak (enunciate) clearly in conversation and general communication.
- Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.
- Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.
- Lifting and moving objects, patients and/or equipment less than 10 pounds
Work Environment:If located at the 500, 505 Building or a remote work location:
- Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
- There are no harmful environmental conditions present for this job.
- The noise level in this work environment is usually moderate.
If located at PACE:
- Work is typically indoors in a clinical setting serving the frail and elderly.
- There may be harmful or hazardous environmental conditions present for this job.
- The noise level in this work environment is usually moderate to loud.
If located in the Community:
- Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.
- Employee will occasionally work outdoors in varied temperatures.
- There may be harmful or hazardous environmental conditions present for this job.
- The noise level in this work environment is usually moderate to loud.
About CalOptima Health:
CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay!
About our Benefits & Wellness options:
At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the
2024 CalOptima Health Benefits Guide regarding our comprehensive benefits and wellness package.
IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONSApplications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is
September 3, 2024 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet.
Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application.
CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics. If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.To apply, please visit: https://jobs.caloptima.org/jobs/manager-grievance-appeals-intake-505-city-parkway-west-california-united-states
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