Grievance & Appeals - Supervisor Grievance & Appeals

JOB SUMMARY: In compliance with federal, state, and accreditation requirement, this position is responsible for overseeing activities and personnel involved in the day to day operations of grievance and appeals for all lines of business. KEY RESPONSIBILITIES: • Provides technical consultation to G&A staff including analysis, problem solving, and decision making of complex cases. Communicates and implements procedural changes in response to new or revised regulatory requirements for multiple lines of business. • Coordinates and/or oversees daily workload and functional activities of the G&A staff. • Analyzes findings of departmental monitoring and corporate internal audits related to G&A. Develops and implements corrective action plans as indicated. • Assists the G&A Manager with external audits, site-visits, department and corporate policy revisions, etc.. Coordinates submission of data for the Annual Data Validation Audit with other departments. Implements various special projects as assigned by the Manager or Compliance Officer. • Collaborates with IS and department staff to improve and/or maintain the Grievance and Appeals Tracking System (GATS) or other systems to meet various reporting requirements. Monitors for data integrity. • Responsible for review and analysis of monthly, quarterly, and annual G&A reporting. • Performs other duties as assigned. QUALIFICATIONS: • Possess strong oral and written communication skills. • Ability to work independently on multiple tasks. • Proficient in Microsoft applications. • Highly organized and attentive to detail. • Strong problem solving and analytical skills. • Successful completion of Health Care Sanctions background check. EDUCATION/EXPERIENCE: • Associates degree plus 5 years' experience in Managed Care, including member services, medical management and/or claims processing OR Bachelor's degree plus 1 year experience, OR each year of experience may be substituted for each year of college not completed. • Knowledge of governmental regulations related to Managed Care Commercial and Medicare programs. • Past supervisory experience preferred. CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin

Created: 2026-03-10