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Director, Grievance & Appeals Resolution Services (GARS)

Director, Grievance & Appeals Resolution Services (GARS)


Job Description


Department(s): Grievance & Appeals

Reports to: Executive Director, Operations

FLSA status: Exempt

Salary Grade: R - $144,000 - $204,000


Job Summary


This position is responsible for the development and management of the Grievance and Appeals Resolution Services (GARS) department. The incumbent will ensure service standards and established policies and procedures regarding the appeals and grievance processes adhere to regulatory requirements. Collaborates regularly with all levels of CalOptima's staff, external contacts with regulatory agencies, health networks, community-based organizations, and medical groups. Stays current with all new regulatory guidelines that impact GARS for all CalOptima programs. Staff development and the ability to build and foster a team environment are essential.

Position Responsibilities:


• Determines strategy, designs compliant processes, and directs the activities of the Grievance and Appeals unit that is responsible for reviewing and resolving member and provider complaints and communicating resolution to members or authorized representatives in accordance with state and federal laws.

• Develops and directs quality and compliance programs as it relates to Grievance and Appeals to ensure performance monitoring, operational reporting, and regulatory reporting.

• Works with internal teams and delegated partners to implement, oversee, and manage any delegated Grievance and Appeals functions.

• Develops and maintains systems for tracking Grievance and Appeals data.

• Provides trend analysis to internal or external stakeholders, as necessary, to escalate issues to appropriate organizational decision-makers.

• Provides internal and regulatory reporting to stakeholders as requested.

• Manages employees directly and through subordinate manager(s); responsible for selecting, training, developing, reviewing, and setting department and individual performance goals, and allocating resources for the GARS department.

• Business lead for all regulatory audits pertaining to Grievance and Appeals.

• Assesses departmental performance in relation to established goals and standards; recommends new approaches, workflows, policies, and procedures to effect continual progress toward goals and standards.

• Develops, maintains, and updates policies, procedures and standards for all GARS activities and member or provider processes related to the Department of Health Care Services (DHCS), Department of Managed Healthcare (DMHC), and Centers for Medicare & Medicaid Services (CMS), Medi-Cal state hearings, Office of Administrative Hearings and Appeals, and external review agencies for CMS.

• Presents to internal and external stakeholders on issues impacting member and provider grievances.

• Keeps current on the local, state, and federal healthcare environment to identify public policy and market trends that may impact GARS. Adjusts internal processes/policies as applicable.

• Develops and monitors departmental budget.

• Other projects and duties as assigned.


Possesses the Ability To:


• Motivate and lead departmental staff and various participants at all levels in the organization.

• Have strong interpersonal skills including coaching staff and handling conflict resolution.

• Ensure timely resolution of member- and provider related problems.

• Oversee the maintenance of records and reports.

• Establish and maintain effective interpersonal relationships across functional and enterprise boundaries and build relationships with other departments, programs, agencies, and the public to achieve business goals.

• Influence the adoption of new concepts to internal and external stakeholders.

• Develop a team of support resources that may not functionally report to the position to achieve the task at hand.

• Identify pertinent policy issues; develop strategies, solutions, and recommendations.

• Analyze health care data to assess the policy implications for CalOptima's programs.

• Communicate clearly and concisely, both verbally and in writing.

• 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.


Experience & Education:


• Bachelor's degree in Healthcare Management or related field, or equivalent combination of education and experience required.

• 5+ years healthcare grievance & appeals experience in a managed care organization required.

• 5+ years of management/leadership experience in a healthcare company required.


Preferred Qualifications:


• Health Maintenance Organization (HMO), Medi-Cal/Medicaid, Medicare and insurance experience or relevant government client or public service experience preferred.

• Current, unrestricted Licensed Vocational Nurse (LVN) or Registered Nurse (RN) License to practice in the State of California is preferred.


Knowledge of:


• Planning, directing, and maintaining compliance with regulatory standards.

• Techniques and methods to organize and manage a department; to include but not limited to training and evaluation of staff.

• Principles and practices of health care service delivery, managed care, health care systems, and medical administration and National committee for Quality Assurance (NCQA) accreditation standards.

• Techniques to serve diverse social and ethnic groups and to communicate effectively with them.

• Medi-Cal, Medicare, Cal MediConnect program services, regulations, and benefits, including state and federal standards and regulations for member and provider rights and responsibilities.

• Covered benefits specified in CalOptima contracts strongly desired.

• Appropriate methods to serve diverse social and ethnic groups.


CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima 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 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 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. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.


Job Location: Orange, California


Position Type:


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Director, Grievance & Appeals Resolution Services (GARS)

Orange, CA
Full Time
Management (Manager/Director of Staff)

Published on 12/03/2021

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