Job Description

Job Duties and Responsibilities:

1. Team Leadership and People Management

• Supervise, lead, and provide day-to-day direction to the Appeals & Grievance team.
• Assign and monitor workloads to ensure timely processing and resolution of grievances, appeals, organization determinations, and Complaint Tracking Module (CTM) cases.
• Conduct regular coaching, performance evaluations, and feedback sessions to support employee development and improve team performance.
• Identify training needs and provide guidance on Medicare Advantage processes, CMS requirements, case handling, and documentation standards.
• Promote accountability, productivity, quality, and adherence to established operational procedures.

1. Appeals and Grievance Operations

• Oversee the receipt, tracking, investigation, processing, and resolution of member and provider grievances and appeals.
• Ensure cases are handled in accordance with applicable Medicare Advantage requirements, CMS guidelines, and internal policies and procedures.
• Monitor standard and expedited appeals, organization determinations, reconsiderations, and grievance cases to ensure compliance with applicable regulatory turnaround times.
• Review complex and escalated cases and provide guidance on appropriate resolution and next steps.
• Ensure appropriate coordination and preparation of case files for Medical Director review and Independent Review Entity (IRE) review, when applicable.
• Oversee the handling and documentation of CTM complaints and ensure timely responses and resolution.

1. Quality Assurance and Regulatory Compliance

• Monitor case accuracy, investigation quality, documentation completeness, and correspondence to ensure compliance with CMS requirements.
• Conduct regular quality reviews and audits of grievance and appeal case files.
• Ensure member and provider communications are clear, accurate, professional, and compliant with applicable regulatory requirements.
• Identify compliance risks, recurring errors, and operational gaps, and implement corrective actions where necessary.
• Monitor regulatory updates and communicate relevant changes to the team.
• Support internal and external audits, CMS audit preparations, regulatory inquiries, and compliance reviews.

1. Performance Monitoring and Reporting

• Establish and monitor team performance metrics, productivity targets, quality scores, and regulatory turnaround times.
• Track and analyze grievance and appeal trends, case volumes, resolution outcomes, and recurring member or provider concerns.
• Prepare and present regular operational reports, including monthly and quarterly performance reports, as required.
• Identify opportunities to improve operational efficiency, case resolution, member experience, and overall team performance.
• Escalate significant operational issues, compliance risks, and performance concerns to management.

1. Stakeholder Coordination and Process Improvement

• Coordinate with Member Services, Medical Directors, providers, internal departments, and external review entities to facilitate appropriate case resolution.
• Serve as an escalation point for complex or sensitive member and provider complaints.
• Participate in the development, review, and updating of Appeals & Grievance policies, procedures, and workflows.
• Recommend process improvements to strengthen compliance, improve turnaround times, and enhance the member experience.
• Perform other duties and responsibilities as assigned by management.

Job Requirements

Experience

• Required: At least 3–5 years of experience in US healthcare, health insurance, Medicare Advantage, or related healthcare operations.
• Required: At least 2–3 years of supervisory or team leadership experience in a healthcare BPO, insurance, or managed care environment.
• Required: Direct experience handling or overseeing Medicare Advantage (Part C) grievances, appeals, and organization determinations.
• Required: Working knowledge of CMS Medicare Advantage requirements, regulatory turnaround times, and appeals and grievance processes.
• Preferred: Experience managing CTM complaints, reconsiderations, IRE referrals, and CMS audit preparation.
• Preferred: Experience in Member Services, Quality Assurance, or healthcare compliance operations.