Manager, Appeals and Grievances General Operations (RN-Clinical)

Salary Range:  $117,509.00 (Min.) - $152,762.00 (Mid.) - $188,015.00 (Max.)

 

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.
 

Job Summary

The Manager, Appeals & Grievances (A&G) & General Operations (Clinical) is responsible for the daily oversight of clinical appeals and grievances functions within the Appeals & Grievances Department to ensure clinical grievances, complaints, appeals and complex issues are investigated and resolved using regulatory guidance across all lines of business. Provides direct supervision to the A&G clinical team and the unit that supports them in order to assure operational effectiveness which includes the implementation and adherence to L.A. Care's Policies & Procedures that meet Centers for Medicare and Medicaid Services (CMS), the California Department of Health Care Services (DHCS), the California Department of Managed Health Care (DMHC), the Managed Risk Medical Insurance Board (MRMIB), National Committee for Quality Assurance (NCQA) and other rules/ regulations/ standards.
 
The Manager is responsible for establishing and monitoring processes to oversee and coordinate the identification, documentation, reporting, investigation and resolution of all member appeals and grievances in a timely and culturally-appropriate manner. Coordinates, tracks, and resolves internal and external appeal and grievance complaints for L.A. Care Plan Partners, including identifying opportunities for improvement.

This position will be a role model for integrity and will establish and maintain effective professional work relationships, working collaboratively with all levels of management and business owners to help guide the discipline of planning, organizing, securing, managing, leading, and controlling resources to achieve specific goals.

Manages all aspects of running an efficient  team, including hiring, supervising, coaching, training, disciplining, and motivating direct-reports. 

Duties

Manage and oversee the handling of clinical grievances and appeals, for L.A. Care and Plan Partner members. Establishes and oversees processes and all relevant member correspondence for accuracy, clarity, and cultural appropriateness and sensitivity.
 
Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member grievances. Serve as the Key Contact for State Fair Hearings, internal and external audits, DMHC and DHCS inquiries. Review and monitor procedures for identifying quality of care issues and work collaboratively with cross-functional departments to appropriately address and resolve member and provider grievances.

Responsible for timely daily operations in the A&G Clinical Services Unit and other general operations units.  Ensures timely appeal and grievance reporting to regulatory agencies, internal Regulatory Affairs and Compliance Department, internal Quality Oversight Committee, etc. Collaborates with cross-functional departments  to ensure the use of appropriate appeal and grievance issue codes, timely resolution, and refers to community partners as appropriate.  

Lead, participate and provide representation of the A&G Team at Internal and External meetings/ workgroups and acts as the point person for A&G Programs especially the Clinical Programs.

Develop and execute on strategic opportunities to improve the overall appeals & grievance process. Create a best in clinical appeals process that is efficient and effective in managing member appeals.

Work cross functionally and collaboratively within Appeals and Grievances with key internal partners to build a high functioning, results oriented environment and organization. 

Duties Continued

Partner with internal and external stakeholders to build and maintain collaborative relationships and partnerships. Identify areas of connection to leverage and create added value for L.A. Care.

Provide input into the development of automation to guide the team to process efficiencies for all lines of business while maintaining compliance and manageable workloads for staff.

Responsible for maintaining and updating on an annual basis, or as necessary, appeal and grievance policies and procedures, member correspondence, etc., co