Senior Manager, Appeals and Grievances Center of Quality and Excellence

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, 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 Senior Manager, Appeals & Grievance (A&G) Center of Quality & Excellence is a strategic leader responsible for driving operational performance, regulatory compliance, service quality, and continuous improvement across all appeals and grievance functions. This position ensures accuracy, completeness, compliance, and audit-readiness of grievance, appeal, and State Fair Hearing case files across all product lines, including Medi-Cal, Medicare, Marketplace, and commercial products. The Senior Manager manages a comprehensive quality and audit program that includes case accuracy audits, documentation integrity reviews, timeliness monitoring, regulatory audit preparation, universe submissions, corrective action management, and governance of policies and standard operating procedures.

 

The Senior Manager collaborates closely with a cross-functional management team to identify systemic issues, strengthen internal controls, and ensure sustainable compliance with Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Centers for Medicare and Medicaid Services (CMS), and National Committee for Quality Assurance (NCQA) requirements. The Senior Manager ensures the A&G department maintains the highest standard of documentation quality, operational integrity, and regulatory alignment.

 

The Senior Manager Manages all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports.  Responsible for driving performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.  Oversees the development, implementation, administration, and maintenance of the department's programs, policies, and procedures. Responsible for driving management and performance to ensure that the team can lead high-level decisions that impact on the success of L.A. Care.

 

Collaborate closely with executive/ senior management to establish goals that align with the company’s mission and vision.

Duties

Plans and implements systems and procedures to maximize operating efficiency and achieve strategic priorities. Strengthens the control environment across A&G by establishing disciplined processes, elevating documentation standards, and ensuring that quality assurance and audit readiness are embedded in daily operations.

 

Manages the A&G quality assurance program, ensuring systematic audits of case accuracy, documentation completeness, decision rationale, classification accuracy, letter quality, and regulatory alignment.

 

Oversees validation of issue codes, categories, decisions, and disposition accuracy for grievance and appeal cases across all lines of business.

 

Conducts quality reviews of delegated entities and plan partners to ensure contractual and regulatory alignment, coordinating with Provider Network Management as appropriate. Ensures continuous monitoring of documentation quality and supports operational teams in remediation of identified gaps.

 

Administers the A&G audit readiness program, ensuring the department maintains sustainable compliance with DHCS, DMHC, CMS, NCQA, and other governing agencies.

 

Oversees preparation for all internal, external, and regulatory audits, including universe submissions, case file reviews, evidence packet integrity, corrective action plans, and readiness assessments. Ensures case file integrity through routine audits validating completeness, accuracy, timeliness, and regulatory adherence.

 

Oversees timeliness monitoring and reporting, identifying trends and partnering with operational teams to implement timely corrective actions.

 

Leads internal mock audits and guides teams through audit-life-cycle activities, from preparation to response to sustainability.

 

Partners with cross-functional departments to strengthen control environments and resolve systemic issues. Strengthens the control environment across A&G by establishing disciplined processes, elevating documentation standards, and ensuring that quality assurance and audit readiness are embedded