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L.A. Care Health Plan · 9 hours ago

Senior Manager, Appeals and Grievances Center of Quality and Excellence

Los Angeles, CA

Full-time

Hybrid

Senior Level

$118K/yr - $188K/yr

6+ years exp

L.A. Care Health Plan is the nation’s largest publicly operated health plan, providing health coverage to low-income residents of Los Angeles County. The Senior Manager, Appeals & Grievance Center of Quality & Excellence is responsible for driving operational performance, regulatory compliance, and service quality across all appeals and grievance functions while managing a comprehensive quality and audit program.

FitnessGovernmentHealth Care

Responsibilities

Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities

Strengthens the control environment across A&G by establishing disciplined processes, elevating documentation standards, and ensuring that quality assurance and audit readiness are embedded in daily operations

Manages the A&G quality assurance program, ensuring systematic audits of case accuracy, documentation completeness, decision rationale, classification accuracy, letter quality, and regulatory alignment

Oversees validation of issue codes, categories, decisions, and disposition accuracy for grievance and appeal cases across all lines of business

Conducts quality reviews of delegated entities and plan partners to ensure contractual and regulatory alignment, coordinating with Provider Network Management as appropriate. Ensures continuous monitoring of documentation quality and supports operational teams in remediation of identified gaps

Administers the A&G audit readiness program, ensuring the department maintains sustainable compliance with DHCS, DMHC, CMS, NCQA, and other governing agencies

Oversees preparation for all internal, external, and regulatory audits, including universe submissions, case file reviews, evidence packet integrity, corrective action plans, and readiness assessments. Ensures case file integrity through routine audits validating completeness, accuracy, timeliness, and regulatory adherence

Oversees timeliness monitoring and reporting, identifying trends and partnering with operational teams to implement timely corrective actions

Leads internal mock audits and guides teams through audit-life-cycle activities, from preparation to response to sustainability

Partners with cross-functional departments to strengthen control environments and resolve systemic issues. Strengthens the control environment across A&G by establishing disciplined processes, elevating documentation standards, and ensuring that quality assurance and audit readiness are embedded in daily operations

Identifies systemic issues, drives corrective action, supports operational improvement, and ensures A&G maintains continuous compliance. Oversees the development, execution, and monitoring of corrective action plans (CAPs) associated with operational, quality, or regulatory audit findings

Monitors CAP performance to ensure timely closure, sustainable outcomes, and ongoing compliance with regulatory expectations. Ensures cross-functional alignment and accountability for quality- and audit-related corrective actions

Translates regulatory expectations, operational requirements, and quality standards into dependable, sustainable, and high-performing quality and audit programs. Oversees creation, annual review, and maintenance of policies, procedures, desktop guides, templates, and decision-support tools for A&G activities

Ensures compliance with evolving regulatory standards and alignment with enterprise governance and operational workflows

Partners with senior management to validate training effectiveness and ensure process adherence across operational teams

Produces and oversees quality, audit, and compliance trend reporting, including timeliness metrics, accuracy outcomes, and recurring error themes

Provides data-driven insights and actionable recommendations to A&G leadership, executive leaders, and cross-functional governance committees

Maintains quality dashboards and partners with analytics teams to strengthen visibility into operational performance and quality indicators

Collaborates with cross-functional management teams to resolve root-cause issues and strengthen processes

Supports enterprise-level initiatives related to service performance, regulatory compliance, audit preparedness, and operational improvement

Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/or executive management to define, prioritize, and develop projects and programs

Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions

Responsible for overseeing and managing the budgets of their respective departments

Manages staff and the day-to-day activities in the department. Participates in the department budgeting process. Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Ensures workforce planning supports quality and audit program needs

Builds a culture of rigor, transparency, analytical curiosity, initiative-taking issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement

Performs other duties as assigned

Qualification

Managed care operationsQuality assuranceAudit readinessRegulatory complianceCorrective action plansLean Six SigmaAnalytic dashboardsProject ManagementAnalytical skillsFinancial principlesLeadership skillsCommunication skillsTeamwork

Required

Bachelor's Degree

At least 6 years of experience working in managed care operations, quality assurance, audit readiness, compliance, or related regulatory positions

At least 5 years of experience in leading, supervising and/or managing staff

Experience in Medicaid, Medicare, and Commercial managed care lines of business

Experience in overseeing quality assurance programs, internal controls, or audit readiness functions within a health plan or similar setting

Strong experience with DHCS, DMHC, CMS, and NCQA requirements related to grievances, appeals, quality-of-care processes, and audit expectations

Experience developing and managing corrective action plans and driving sustainable remediation

Experience collaborating with delegated entities, plan partners, or subcontracted networks

Proven ability to lead universe submissions, mock audits, and regulatory audit responses

Strong leadership and stakeholder management skills

Expert knowledge of regulatory requirements, audit processes, and quality assurance practices in managed care

Strong analytical and critical thinking skills, including ability to translate trends into corrective actions

Ability to design, implement, and sustain standardized processes and internal control structures

Proficiency with Microsoft Office, case management systems, and reporting tools

Strong people skills for building relationships, fostering teamwork, and creating a positive work environment

Ability to guide and support team members

Strong attention to detail and ability to manage multiple priorities and tight deadlines

Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision

Skilled in mediating disputes and resolving conflicts in a fair and constructive manner

Must have a deep understanding of financial principles

Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation

Demonstrated ability to make informed decisions

Exceptional verbal, written communication, and presentation skills. Includes executive communication and the ability to translate trends and other findings into actionable recommendations

Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges

Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals