Senior Manager, Appeals and Grievances
L.A. Care Health Plan
full-time
Posted on:
Location Type: Office
Location: Los Angeles • California • United States
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Salary
💰 $117,509 - $188,015 per year
Job Level
About the role
- Drive operational performance, regulatory compliance, service quality, and continuous improvement across all appeals and grievance functions.
- Ensure accuracy, completeness, compliance, and audit-readiness of grievance, appeal, and State Fair Hearing case files.
- Manage a comprehensive quality and audit program that includes case accuracy audits, documentation integrity reviews, and timeliness monitoring.
- Collaborate closely with cross-functional management teams to strengthen internal controls and ensure sustainable compliance with regulatory requirements.
- Oversee the development, implementation, administration, and maintenance of the department's programs, policies, and procedures.
- Produce and oversee quality, audit, and compliance trend reporting.
Requirements
- 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
- 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
- Proven ability to lead universe submissions, mock audits, and regulatory audit responses
- Strong analytical and critical thinking skills, including ability to translate trends into corrective actions
- Proficiency with Microsoft Office, case management systems, and reporting tools
Benefits
- Paid Time Off (PTO)
- Tuition Reimbursement
- Retirement Plans
- Medical, Dental and Vision
- Wellness Program
- Volunteer Time Off (VTO)
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
managed care operationsquality assuranceaudit readinesscompliancegrievancesappealscorrective action plansregulatory audit responsesanalytical skillscritical thinking
Soft skills
leadershipsupervisioncollaborationcommunicationorganizational skills
Certifications
Bachelor's Degree