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Job Details

Associate Director Grievance amp Appeals

Company name

Orange, CA, United States

Employment Type


Posted on
Nov 22, 2021

Apply for this job


Associate Director (Grievance & Appeals)


Job Description
Department(s): Grievance & Appeals
Reports to: Director, GARS
FLSA status: Exempt
Salary Grade: P - $117,000 - $165,000

Job Summary

The Associate Director (Grievance and Appeals) is responsible for the development and management of the Grievance and Appeals Resolution Services (GARS) Department. The incumbent will ensure full compliance with all state and federal laws, regulations, rules, and contract requirements as set forth by the Department Health Care Services (DHCS), Department of Managed Health Care (DMHC), the Centers for Medicare and Medicaid Services (CMS), and any other governmental entities with regulatory authority. The incumbent participates in all regulatory audits pertaining to grievance and appeals and stays current with all new regulatory guidelines that impact Grievance and Appeals for all CalOptima programs.

Position Responsibilities:



  • Maintains oversight of member grievances, appeals, State Fair Hearings, and Administrative Law Judge (ALJ) hearings in adherence with regulatory requirements. Ensures quality assurance standards within clinic operations are met or exceeded through effective performance monitoring and utilization of nursing practice standards.
  • Ensures that clinical and medical protocols and rules for the grievance and appeals process are followed.
  • Reviews and analyzes 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. Sets direction and goals for nursing and clinical managers and supervisors to ensure clinic operations integrate with other GARS program services.
  • Manages employees directly and through subordinate manager(s). Is responsible for selection, training, developing, reviewing, and setting departmental and individual performance goals to enhance professional development.
  • Designs and implements resource and capacity management strategies to maximize efficiencies in grievance and appeals handling.
  • Proactively communicates with and advises key leadership regarding process improvements, project status, risks, issues, and priorities with leadership.
  • Leads, coordinates, and monitors policy and procedural changes and maintains the process for revision and implementation that supports plan regulatory compliance.
  • Performs audits to monitor compliance with policies and regulatory requirements, as well as ensures process and operational efficiency.
  • Co-leads Grievance and Appeals quarterly committee meeting and attends all internal committees within the CalOptima organization to report activities and trends.
  • Oversees staff assignments to ensure effective allocation of resources to ensure state and federal regulations are met and establishes production standards for the department.
  • Responsible for job descriptions, interviews, the hiring of new staff members, orientation, training programs for Grievance and Appeals staff, both new and existing, and annual performance evaluations for assigned staff.
  • 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.
  • Performs special projects and other duties as assigned.


Knowledge & Abilities:




  • Communicate effectively with health professionals and administrators, both verbally and in writing.
  • Work in an extremely fast-paced environment with multiple competing priorities and matrix reporting relationships.
  • Make decisions in a timely manner and clearly communicate to all organizational levels in both a vertical and horizontal manner.
  • Present statistical and technical Grievance and Appeals data in a clear and understandable manner utilizing appropriate visual aids.
  • Motivate and lead departmental staff and various participants at all levels in the organization.
  • 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.
  • 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.



Experience & Education:





  • Bachelor's degree or equivalent combination of education and experience required.
  • 5 years of healthcare grievance and appeals experience in a managed care organization required.
  • 4 years of leadership experience in a healthcare company required.
  • Previous state or federal healthcare audit experience 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:




  • Knowledge of State and Federal regulatory statutes, including Medicare Parts C, D, and Medicaid.
  • Strong interpersonal skills including coaching staff and handling conflict resolution is required.
  • Strong analytical, problem solving, and interpersonal skills.
  • Self-starter with outstanding critical thinking and relationship building skills.
  • Proficient with Microsoft Office (Word, Excel, and PowerPoint).
  • Excellent verbal and written communication skills.
  • Principles and methods of planning, directing, and maintaining compliance with regulatory standards.
  • Principles and practices of health care service delivery, managed care, health care systems, medical administration, and NCQA accreditation standards.
  • Medi-Cal, Medicare, and Cal MediConnect program services, regulations, and benefits, including state and federal standards and regulations for member and provider rights and responsibilities.
  • Appropriate techniques to serve diverse social and ethnic groups and to communicate effectively with them.


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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