Senior Director and Grievance Officer, Appeals and Grievances

Job Summary

The Senior Director and Grievance Officer, Appeals and Grievances (A&G), is responsible for leadership, operational execution, clinical and regulatory oversight, and enterprise governance of L.A. Care’s grievance, appeal, and State Fair Hearing functions across all product lines. This position ensures all cases are processed accurately and consistently with exceptional quality, and within required timeframes in alignment with federal and state regulations, contractual obligations, accreditation standards, and internal policies.

The Senior Director directs a comprehensive operating model that includes centralized intake and triage, general and clinical A&G operations, regulatory auditing and reporting, quality assurance, internal controls, and enterprise-level grievance governance. The Senior Director oversees staff and ensures the organization maintains strong regulatory compliance, service quality, and documentation standards.

The Senior Director collaborates extensively with cross-functional key stakeholders to address systemic issues, strengthen preventive controls, improve service delivery, and support enterprise audit readiness. The Senior Director embodies a commitment to operational excellence, accountability, equitable member experience, and disciplined governance.

This position is responsible for directing all aspects of running an efficient team, including hiring, supervising, coaching, training, disciplining, and motivating direct reports. Develops strategic plans, drives change and influences critical business outcomes. Oversees operations, ensuring efficiency and effectiveness. Steer top-level decision-making and implement initiatives that drive organization's forward.

Duties

Proactively translates regulatory, clinical, and service strategy into disciplined operational execution by setting clear expectations, establishing consistent processes, and ensuring teams have the tools, training, and data needed to perform at a high level. Serves as the connective tissue between key stakeholders, ensuring complex regulatory requirements are converted into clear workflows, strong internal controls, and reliable, audit-ready outcomes. Strengthens organizational trust and supports L.A. Care’s mission by leading with transparency, leveraging data-driven insights, and prioritizing member and provider experience within a highly regulated environment.

Provides senior leadership oversight to ensure all A&G operations are compliant, audit-ready, efficient, and aligned with organizational performance expectations. Leads and is accountable for the overall strategy, direction, and day-to-day operations of A&G, including intake, triage, case handling, documentation, clinical decision coordination, State Fair Hearings, and regulatory submissions. Establishes departmental goals, key performance indicators (KPIs), dashboards, reporting structures, and operating rhythms to monitor and drive performance across all A&G functions. Ensures consistent application of regulatory and internal requirements.

Drives operational reliability through standardized processes, workforce management, and transparent performance reporting. Ensures operational capacity aligns with demand through forecasting, workload monitoring, and resource planning. Fosters a culture of proactive issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.

Serves as the enterprise authority on grievance and appeal requirements and ensures all case handling meets federal and state standards. Interprets, applies, and operationalizes regulatory requirements and guidance. Oversees regulatory reporting, including universe submissions, timeliness validation, case audits, quality-of-care review documentation, and readiness assessments. Ensures accurate, complete, and compliant preparation of State Fair Hearing cases, medical records, and evidentiary documentation. Responds to regulatory inquiries and leads root-cause analysis, corrective actions, and sustainability plans for identified compliance issues. Reviews and approves A&G policies, procedures, templates, letters, decision frameworks, and escalation pathways.

Oversees the clinical components of A&G operations to ensure appropriate medical necessity review, accurate and high-quality clinical documentation, and consistent application of evidence-based guidelines to support high-quality member care. Partners with key stakeholders to ensure clinical decision stewardship and alignment with regulatory expectations. Ensures timely identification, escalation, and resolution of quality-of-care concerns in collaboration with key stakeholders. Ensures consistency in documentation of clinical rationale, decision accuracy, and regulatory adherence across all clinical case types.

Leads a unified quality and internal control environment spanning general operations, clinical operations, and regulatory auditing. Oversees the A&G quality assurance program, ensuring ongoing monitoring for accuracy, documentation quality, and compliance. Ensures development and maintenance of standard operating procedures, desktop guides, decision trees, templates, and training materials. Directs all audit readiness activities, including internal audits, mock audits, and enterprise corrective action plans. Collaborates with internal leaders to strengthen controls and ensure sustainable compliance. Oversees training and competency validation programs for all A&G personnel, ensuring readiness and capability across the department.

Duties Continued

Leads enterprise-wide integration of A&G insights into systemic improvements and supports risk mitigation across operational domains. Partners with internal departments to resolve root-cause issues and reduce grievance drivers. Collaborates with internal departments to support regulatory filings, investigations, enterprise risk assessments, and Corrective Action Plan management. Engages with external stakeholders to resolve escalated member issues and improve service continuity. Provides leadership support and A&G expertise in enterprise forums, oversight committees, and quality and service governance structures.

Ensures transparent, accurate, and actionable reporting that supports operational decision-making and continuous improvement. Oversees reporting of case volumes, trends, timeliness, quality-of-care findings, regulatory metrics, and systemic issues. Ensures high-quality analytics that inform operational refinements, service improvements, and strategic initiatives. Presents findings to key stakeholders, identifying opportunities for enterprise improvement.

Leads a large, multi-disciplinary leadership team and ensures a high-performing, accountable, and engaged workforce. Manages leadership teams responsible for general operations, clinical services, quality assurance, and regulatory auditing. Promotes a culture of operational excellence, service commitment, accountability, integrity, and continuous learning. Supports succession planning and leadership development across multiple levels within the A&G organization.

Develops goals, objectives and actions plans for assigned staff which includes full management responsibility for the hiring, performance reviews, salary reviews and disciplinary matters for direct reporting employees. Conducts strategic planning to utilize resources to meet current and future departmental and Enterprise-wide goals. Leads discussions on policy operationalization and oversees key policy perspective sharing. Manages budgets and resources effectively. Identifies and drives change initiatives. Develops and implements communication strategies. Collaborates with cross-functional teams to achieve common goals. Represents the company or organization in external interactions. Identifies and actualizes enhancements to support company vision. Develops and maintains relationships with key stakeholders.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:

At least 9 years of experience in health plan operations, managed care, A&G, utilization management, clinical operations, or regulatory compliance.

At least 8 years of leading staff, supervisor/management experience.

Experience leading teams, projects, initiatives, or cross-functional groups.

Extensive leadership experience in Medicaid, Medicare, and Commercial managed care lines of business., with deep understanding of their operational, regulatory, and service requirements.

Experience navigating regulatory and accreditation requirements, with a strong track record of applying complex regulatory standards to grievance, appeal, and quality-of-care operations.

Experience improving operational accuracy, strengthening documentation quality, and ensuring consistent alignment with federal and state regulatory expectations.

Experience leading organizations through high-stakes regulatory audits, with a consistent record of achieving compliant outcomes and driving sustainable remediation.

Preferred:

Extensive experience working within delegated, plan-partner, or subcontracted network environments, with demonstrated ability to oversee performance, ensure compliance, and manage complex accountability structures.

Experience leading vendor management activities, including performance oversight, Service Level Agreement (SLA) adherence, quality monitoring, and alignment with regulatory and contractual requirements.

Experience developing analytic dashboards and visualization tools (e.g., Power BI, Tableau) to support trend analysis, performance monitoring, and decision-making.

Skills

Required:

Exceptional interpersonal and leadership capabilities, with the ability to inspire, develop, and empower teams while driving accountability, consistency, and high performance across all levels.

Expert knowledge of grievance, clinical decision-making, and managed care regulatory standards, with the ability to translate complex requirements into effective operational processes.

Advanced strategic and analytical skills to interpret trends, assess operational and regulatory risk, and design sustainable, data-driven solutions.

Deep and comprehensive understanding of regulatory requirements for all lines of business.

Ability to lead effectively in complex, high-volume, and highly regulated environments with competing priorities, rapid demand shifts, and significant compliance requirements.

Exceptional influence and stakeholder engagement skills to translate complex concepts into clear, actionable guidance for diverse audiences.

Strong leadership presence and leadership acumen, with demonstrated success managing, mentoring, and developing multi-level teams in operational and regulatory disciplines.

Ability to design, implement, and sustain standardized processes, governance frameworks, and internal control structures that enhance accuracy, compliance, and operational reliability.

Strong planning, prioritization, and organizational skills with attention to detail and a proven ability to manage multiple concurrent priorities with urgency, accuracy, and sound judgment.

Proficient with Microsoft Office, reporting platforms, and case management systems, with the ability to leverage technology to improve operational visibility and performance.

Ability to lead comprehensive regulatory audit readiness and response efforts, including universe submissions, documentation validation, corrective action development, and sustainability planning.

Ability to lead operational transformation initiatives while maintaining a strong culture of regulatory compliance, accountability, and service excellence.

Ability to lead technology-enabled operational improvements, including system implementation, enhancement prioritization, and maintenance oversight to drive efficiency and reliability.

Ability to think long-term and develop strategies that align with the overall goals of the organization.

Ability to make sound and timely decisions.

Ability to adapt to changing situations and adjust strategies accordingly.

Ability to adapt to a fast-paced and evolving environment and to lead others through change.

Exceptional interpersonal, verbal, and written communication skills, including executive communication with ability to produce audit-ready documentation.

Excellent ability and knowledge in analyzing data, identifying problems, and making informed decisions, often in complex or ambiguous situations.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

This position requires work after hours, on weekends, holidays, a hybrid remote schedule, occasional flexibility in hours/shift in critical situations and work on-call.