Supervisor Grievance and Appeals

About the role

We are hoping you will join us as a Supervisor Grievance and Appeals and help shape the future of healthcare where you'll be an integral part of our GA - Provider Disputes team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Partial Telework. If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. The Supervisor Grievance and Appeals will be responsible for the daily operations of Grievance and Appeals Resolution Services (GARS). You will supervise staff and provide the necessary training and guidance needed. You will work closely with the trainer, departmental audit team and business analyst to identify training opportunities, patterns and trends from the complaints and opportunities to streamline and improve processes. You will stay up to date on the latest information about CalOptima Health's member benefits and regulatory changes and ensure adherence to established policies and procedures regarding the appeals and grievance process. Together, we are building a stronger, more equitable health system.

Responsibilities

• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
• Provides guidance and supervises the day-to-day activities of the team to ensure compliance with company policies and regulatory requirements.
• Assists in the hiring process and provides ongoing staff training as needed.
• Supervises and supports staff performance, including performance measurement, evaluation and professional development.
• Facilitates one-on-one meetings with staff to review monthly progress regarding performance.
• Manages case inventory to ensure regulatory and departmental standards are met.
• Handles escalated member or provider cases/calls as needed.
• Provides prompt communication to staff and conducts monthly unit meetings to review changes to programs or training issues.
• Collaborates with leadership and staff to set work performance standards and determine assignment priorities.
• Evaluates departmental work procedures to identify inefficiencies and areas for improvement.
• Collects and analyzes relevant information to resolve process-related issues, recommends updates and communicates actionable solutions to management for implementation.
• Comple