NEOGOV · 4 hours ago
Sr Manager, Grievance & Appeals Resolution Services (Sr. Manager II)
Orange, CA
Full-time
Hybrid
Senior Level
$133K/yr - $213K/yr
5+ years expCalOptima is a mission-driven community-based organization dedicated to serving member health with excellence and dignity. The Sr Manager, Grievance & Appeals Resolution Services will provide oversight and leadership to the Grievance and Appeals Resolution Services department, ensuring compliance with regulatory guidelines and enhancing member satisfaction through effective management and collaboration.
GovTechHuman ResourcesInformation TechnologySoftware
Responsibilities
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, manages, trains, supports, develops and evaluates direct reports
Directs work assignments, measures results and initiates personnel actions
Oversees staff assignments to ensure effective allocation of resources to ensure state and federal regulations are met and establishes production standards for the department
Assists the director on key initiatives, including special review, departmental initiatives and strategic planning efforts
Assists department leadership in the management of critical business risks by communicating best practices, promoting process improvement, and monitoring remediation activities
Collaborates regularly with all CalOptima Health's staff levels and external contacts with regulatory agencies, health networks, community-based organizations and medical groups
Leads, coordinates, and monitors policy and procedural changes and maintains the process for revision and implementation that supports plan regulatory compliance
Co-leads Grievance and Appeals quarterly committee meetings and attends all internal committees within the CalOptima Health organization to report activities and trends
Maintains current knowledge of regulatory requirements pertinent to grievance and appeals including DHCS, CMS, DMHC, and National Committee for Quality Assurance (NCQA)
Participates in all state and federal regulatory audits as the business lead as it relates to grievance and appeals
Ensures that regulatory protocols and rules for the grievance and appeals process are followed
Manages and leads all operational and other non-compliance audits
Collaborates across all department areas within GARS, focusing on process improvements and training needs based on internal and external audit outcomes
Acts as a trusted advisor by fostering strong relationships with internal business areas and external engagement partners
Reviews and analyzes member and provider appeals, grievances, and State Fair Hearing data along with audit results to improve root causes of member dissatisfaction and implements action plans and workflows for improvement to achieve member/provider satisfaction and operational effectiveness when assigned to member grievances and appeals
Designs and implements resource and capacity management strategies to maximize efficiencies in grievance and appeals handling, and audits and training
Leads the development of a grievance and appeals training program
Proactively communicates with and advises key leadership regarding process improvements, project status, risks and issues
Performs audits and oversight to monitor compliance with policies and regulatory requirements, as well as ensure process and operational efficiency
Completes other projects and duties as assigned
Qualification
Required
Bachelor's degree PLUS 5 years of healthcare grievance and appeals experience in a managed care organization required; 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
4 years of leadership experience in a healthcare company required
Previous state or federal healthcare audit experience required
Preferred
Health Maintenance Organization (HMO), Medi-Cal/Medicaid, Medicare and insurance experience or relevant government client or public service experience
Current, unrestricted Licensed Vocational Nurse (LVN) OR Registered Nurse (RN) License to practice in the State of California
Benefits
CalPERS pension program and additional retirement packages.
A generous PTO program
A quality work life balance
Various wellness programs
Tuition Reimbursement
Professional development opportunities
Career development opportunities
Flexible scheduling
Company
NEOGOV
NEOGOV is the leading provider of workforce management software uniquely designed for the public sector, education, and public safety.
501-1000 employees
H1B Sponsorship
NEOGOV has a track record of offering H1B sponsorships. Please note that this does not
guarantee sponsorship for this specific role. Below presents additional info for your
reference. (Data Powered by US Department of Labor)
Distribution of Different Job Fields Receiving Sponsorship
Represents job field similar to this job
Trends of Total Sponsorships
2025 (13)
2024 (10)
2023 (10)
2022 (18)
2021 (14)
2020 (16)
Funding
Current Stage
Late StageTotal Funding
$700MKey Investors
Warburg Pincus
2025-07-28Secondary Market· $700M
2025-07-28Acquired
2021-06-02Private Equity
Leadership Team
Shane Evangelist
CEO
Brandon McDonald
Head Of Marketing
Recent News
Canada NewsWire
2025-11-14
2025-11-14
Government Technology US
2025-10-31
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