Senior Manager, Appeals and Grievances Center of Quality and Excellence

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 in daily operations.

Identifies systemic issues, drives corrective action, supports operational improvement, and ensures A&G maintains continuous compliance. Oversees the development, execution, and monitoring of corrective action plans (CAPs) associated with operational, quality, or regulatory audit findings.

Monitors CAP performance to ensure timely closure, sustainable outcomes, and ongoing compliance with regulatory expectations. Ensures cross-functional alignment and accountability for quality- and audit-related corrective actions.

Translates regulatory expectations, operational requirements, and quality standards into dependable, sustainable, and high-performing quality and audit programs. Oversees creation, annual review, and maintenance of policies, procedures, desktop guides, templates, and decision-support tools for A&G activities.

Ensures compliance with evolving regulatory standards and alignment with enterprise governance and operational workflows.

Duties Continued

Partners with senior management to validate training effectiveness and ensure process adherence across operational teams.

Produces and oversees quality, audit, and compliance trend reporting, including timeliness metrics, accuracy outcomes, and recurring error themes.

Provides data-driven insights and actionable recommendations to A&G leadership, executive leaders, and cross-functional governance committees.

Maintains quality dashboards and partners with analytics teams to strengthen visibility into operational

performance and quality indicators.

Collaborates with cross-functional management teams to resolve root-cause issues and strengthen processes.

Supports enterprise-level initiatives related to service performance, regulatory compliance, audit preparedness, and operational improvement.

Implements and provides guidance to the departmental and organizational processes and policies and works with senior and/or executive management to define, prioritize, and develop projects and programs.

Responsible for Identifying complex problems and reviewing related information to develop and evaluate options and implement solutions.

Responsible for overseeing and managing the budgets of their respective departments.

Manages staff and the day-to-day activities in the department. Participates in the department budgeting process.  Responsible for scheduling, training, performance, corrective actions, mentoring, and developing of the team(s). Foster and promote a culture of transparency, continuous improvement, accountability, and shared ownership of enterprise goals. Mentors and develops staff, building technical and critical thinking skills across the team. Ensures workforce planning supports quality and audit program needs.

Builds a culture of rigor, transparency, analytical curiosity, initiative-taking issue identification, cross-functional communication, accountability, transparency, and continuous operational improvement.

Performs other duties as assigned.

Education Required

Education Preferred

Experience

Required:

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.

Experience in overseeing quality assurance programs, internal controls, or audit readiness functions within a health plan or similar setting.

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.

Experience collaborating with delegated entities, plan partners, or subcontracted networks.

Preferred:

Experience with analytic dashboards and visualization tools (Power BI, Tableau).

Skills

Required:

Proven ability to lead universe submissions, mock audits, and regulatory audit responses.

Strong leadership and stakeholder management skills.

Expert knowledge of regulatory requirements, audit processes, and quality assurance practices in managed care.

Strong analytical and critical thinking skills, including ability to translate trends into corrective actions.

Ability to design, implement, and sustain standardized processes and internal control structures.

Proficiency with Microsoft Office, case management systems, and reporting tools.

Strong people skills for building relationships, fostering teamwork, and creating a positive work environment.

Ability to guide and support team members.

Strong attention to detail and ability to manage multiple priorities and tight deadlines.

Excellent ability to set clear goals, develop strategic plans to achieve those goals, and inspire others to work towards a shared vision.

Skilled in mediating disputes and resolving conflicts in a fair and constructive manner.

Must have a deep understanding of financial principles.

Ability and excellent knowledge in developing and managing budgets, forecasting future financial outcomes, and making informed decisions about resource allocation.

Demonstrated ability to make informed decisions.

Exceptional verbal, written communication, and presentation skills. Includes executive communication and the ability to translate trends and other findings into actionable recommendations.

Deep understanding of the industry, market dynamics, and organizational operations to identify opportunities and navigate challenges.

Strong ability and knowledge to analyze market trends, anticipate future changes, and develop long-term strategies that align with the company's goals.

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.

This position requires handling various caseloads and flexibility to adapt to changing priorities which may include but not limited to redistributed work assignments, team projects, and other priorities as assigned.