Senior Manager, Clinical Appeals Grievances

The Senior Manager, Clinical Appeals & Grievances provides strategic and operational leadership for the Clinical Appeals & Grievances function, ensuring timely, high-quality, and compliant review of clinical appeals and/or grievance cases. This role oversees day-to-day operations, leads internal teams, and partners with cross-functional leaders to optimize workflows, standardize processes, and drive continuous improvement. As a subject matter expert in Appeals & Grievances, the Senior Manager leverages data, performance metrics, and industry best practices to enhance operational efficiency, ensure regulatory compliance, and support organizational goals for quality, growth, and member satisfaction. Job Description Oversee daily operations, delegate work, and monitor productivity, quality and operational performanceEnsure Appeals and Grievances processes comply with all regulatory and organizational requirementsAssess staffing needs and support organizational design and workforce planning initiativesLead, coach, and develop individual contributors and people leaders to achieve performance and operational goalsProvide guidance on internal policies, procedures, and regulatory requirements.Standardize workflows and implement best practices to improve production, quality, compliance, and efficiencyPartner with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gapsOversee C2C Innovative Solutions, Fair Hearing, and External Appeal processes to ensure timely and complaint case managementManage vendor performance and ensure service levels and compliance expectations are achievedBuild and sustain collaborative relationships across departments to drive operational improvements and resolve process concernsAnalyze operational trends, identify performance gaps and implement corrective actionsPrepare and review operational reports and performance metrics to make, guide, and support informed business decisionsAdditional duties as assigned Minimum Qualifications Bachelor's degree from an accredited institution or equivalent work experienceRN or LPNWork experience with utilization management or appeals and grievance processingExperience requiring understanding of healthcare payer operations, regulatory requirements, and compliance implicationsDemonstrated success driving high performance and quality outcomes in a fast-paced, regulated environment Preferred Qualifications MBA or master's degree from an accredited institution with focus on business or healthcare administrationDemonstrated understanding of Utilization Review Guidelines (NYS ART 44 and 49 PHL), InterQual, Milliman or Medicare local coverage guidelinesLeadership experience in a focus area of operational excellence or auditExperience developing strategy and processes for a department or functionExperience managing vendors as an extension of a core teamExperience working and/or managing in a virtual environmentPrior experience leading a team of people leaders Hiring Range*: Greater New York City Area (NY, NJ, CT residents): $122,900 - $188,020All Other Locations (within approved locations): $105,100 - $160,480 As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision. In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live. The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.