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Supervisor, Grievance and Appeals (Non-Clinical)

Supervisor, Grievance and Appeals (Non-Clinical)


Job Description


Department(s): Grievance and Appeals Resolution Services (GARS)

Reports to: Manager, GARS

FLSA status: Non -Exempt

EEOC Classification: Professionals

Salary Grade: L - $77,000 - 109,000


Job Summary


The Supervisor Grievance and Appeals (GARS) is responsible for the daily operations of GARS and supervision of staff. The incumbent will provide necessary training and guidance to the staff as needed, and will work closely with the trainer, departmental audit team, and business analyst to identify training opportunities, patterns, and trends from the complaints and opportunities to streamline and improve processes. The incumbent will notify managers and director of findings.


The incumbent is responsible for staying up to date on the latest information about CalOptima's member benefits and regulatory changes and ensure adherence to established policies and procedures regarding the appeals and grievance process.


Position Responsibilities:


• Supervises and manages the performance of the Resolution Specialist and/or Program Assistant teams.

• Monitors team performance and trends, and coaches' staff to ensure adherence to policies, procedures, and the highest level of customer service.

• Manages case inventory to ensure regulatory and departmental standards are met.

• Writes and delivers job performance evaluations for staff, responsible for the professional and performance development of the staff.

• Assists in the hiring process and provides ongoing staff training as needed.

• Handles escalated member or provider cases/calls as needed.

• Responsible for prompt communication with staff. Conducts monthly unit meetings to review any changes to programs or training issues.

• Facilitates one-on-one meetings with staff to review monthly progress regarding performance.

• Sets or recommends work performance standards; collaborates with staff to determine assignment priorities.

• Reviews work procedures and recommends or changes procedures to improve efficiency.

• Recognizes and resolves problems impacting department processes by collecting and analyzing information; communicates suggestions to management and develops/implements solutions as appropriate.

• Other projects and duties as assigned.


Possesses the Ability To:


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

• Work independently and with minimal supervision with highly confidential information per Health Insurance Portability and Accountability Act (HIPAA) regulations.

• Manage the tracking of multiple tasks in an efficient manner to ensure completion of all assigned projects.

• Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, and the public.

• Encourage the quality performance and development of subordinate staff.

• Plan, organize, and prioritize work.

• Work under pressure resulting from type of work and deadlines.

• 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:


• High School diploma or equivalent required.

• 3+ years of Health Care Management experience, preferably in a Managed Care environment in related areas of responsibility of Utilization Management, Quality Management, Customer Service, and Grievances and Appeals required.


Preferred Qualifications:


• Bachelor's degree in Business Administration or related field, or equivalent work experience in Health Care Management preferred.

• 2+ years of Supervisory or Lead work experience preferred.

• Health Maintenance Organization (HMO), Medi-Cal/Medicaid, Medicare, and Health Services experience preferred.

• Experience in Medi-Cal or Medicare regulatory guidelines for Appeals and Grievances preferred.

• Experience with Medi-Cal and Medicare claims billing guidelines (i.e., Health Care Financing Administration [HCFA] 1500, Universal Billing 92 [UB] 92, Coordination of Benefits [COB], including Current Procedural Terminology [CPT], ICD-10 and Healthcare Common Procedure Coding System [HCPCS] codes.) preferred.


Knowledge of:


• Medi-Cal and Medicare program regulations, including State and Federal standards and regulations for member and provider rights and responsibilities.

• Principles and practices of the managed health care systems, and medical administration and National Committee Quality Assurance (NCQA) Accreditation standards.


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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Supervisor, Grievance and Appeals (Non-Clinical)

Orange, CA
Full Time
Early Career (2+ yrs experience)
Some College Completed

Published on 11/08/2021

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