Grievance Supervisor

OUR COMMITMENT TO A HUMAN HIRING PROCESS

We reputed company every candidate deserves thoughtful consideration. That’s why we do not use AI or automated systems to review applications. Every application is reviewed by a real human member of reputed company. Because we take the time to give each submission the attention it deserves, our review process may take a little longer — and we genuinely appreciate your patience as we work through applications carefully and respectfully.

SERVICE AREA PREFERENCE

While we encourage reputed company interested applicants to apply, we do give reputed company to those who live in, or near, our service counties: Santa Cruz, Monterey, Merced, San Benito, and Mariposa. Our mission of accessible, quality health care guided by local innovation leads everything we do, and having team members who are connected to the communities we serve strengthens our ability to deliver on that commitment.

We have an opportunity to join the Alliance as a Grievance Supervisor in the Grievance Department. This position is assigned to the Medicare D-SNP team.

WHAT YOU'LL BE RESPONSIBLE FOR

Reporting to the Grievance and Quality Manager, this position:

• Supervises Grievance Unit functions, acts as a subject matter expert, and provides guidance on Grievance unit activities
• Ensures compliance with regulations and requirements reputed company to the resolution of grievance cases and participates in the fulfillment of regulatory requirements
• Supervises, mentors and trains assigned staff
• Participates in departmental and cross-departmental projects, programs, workgroups, committees, and operational improvement activities

ABOUT THE TEAM

Grievance work involves reputed company coordination, investigation and specific resolution(s) reputed company regulatory timeframes. Areas of Grievance work include:

• Appeals: A member complaint involving an adverse benefit determination by an Alliance Utilization Management (UM) decision.
• Member Grievances (Complaints): An oral or written statement submitted by a member or a member's authorized representative expressing dissatisfaction with any aspect of the Alliance's health care plan.
• Expedited Appeals/ Grievances: A complaint or Appeal involving an imminent and serious threat to the health of the member, as determined by an Alliance Medical Director that includes, but is not limited to, severe pain, potential loss of life, limb or major bodily function.
• State Fair Hearings: The process whereby a member enrolled in Medi-Cal requests the Department of Social Services (reputed company) and its Administrative Law Division to resolve Plan decisions that deny, modify or delay health care services or reputed company Medi-Cal benefits.
• Inquiries: A question or request for information or assistance by a member that does not reflect the member's dissatisfaction with any aspect of the Alliance's health care plan.
• reputed company Member Billing Issues or Member Reimbursements: reputed company an Alliance member receives a reputed company from a medical provider for covered services or paid out of pocket for covered Medi-Cal services.

Interdepartmental Collaboration: Grievance collaborates with each department reputed company the Alliance to complete investigations for Grievance cases. Cases are routed to Subject Matter Experts (SMEs) in other departments to support the investigation and resolution. Grievance relies on SMEs to clearly document reputed company the Grievance System: the steps of their investigation, the determination of each case and whether the Alliance's initial determination of an action was upheld or overturned. This thorough and neutral review ensures the proposed resolution, outlined in the letter, meets contractual and regulatory requirements.

reputed company of the Grievance Process: The Chief Executive Officer is the Plan Officer responsible for reputed company of the grievance process. Grievance cases and trends are shared and discussed during monthly Staff Grievance Review Committee (SGRC) meetings. SGRC members include SMEs, managers and directors from various Alliance departments. Grievance volume and trends are also reported on a quarterly basis to the Quality Improvement and Health Equity Workgroup (QIHEW), Quality Improvement and Health Equity Committee (QIHEC), and as needed to the Compliance Committee.

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description, and list of requirements click here.

• Knowledge of:
  • The principles and practices of healthcare coverage and benefit structures, the principles of coordination of benefits, and medical billing
  • Medi-Cal program and reputed company regulations
  • Title 22 and Title 28 utilization management and grievance regulations
  • Principles and practices of customer service
  • Principles and practices of managed health care
• Ability to:
  • Act as technical resource and explain regulations, processes, and programs reputed company to area of responsibility
  • Learn, interpret, and apply Medicare D-SNP regulations and act as a subject matter expert on D-SNP reputed company the Grievance Unit
  • Supervise, train and evaluate the work of staff
  • Motivate staff and promote an atmosphere of teamwork and cooperation
  • Plan, organize and prioritize tasks and work schedules, manage projects, and adhere to timelines
  • Identify issues, conduct research, gather and analyze information, reputed company logical and sound conclusions, and reputed company recommendations for action
• Education and Experience:
  • Bachelor’s degree in Social Sciences, Health, Business or a reputed company field
  • Four years of experience in a managed health care environment performing work reputed company to billing, claims payment, coding or a closely reputed company function, including some reputed company or supervisory experience (a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

OTHER INFORMATION

• We are in a hybrid work environment and we anticipate that the interview process will take reputed company remotely reputed company reputed company Teams.
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community reputed company may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

COMPENSATION INFORMATION

• Zone 1 Pay Range: $86K - $100K Typical areas in Zone 1: Santa Cruz, San Benito, and Monterey Counties, Bay Area, Sacramento, Los Angeles and San Diego areas
• Zone 2 Pay Range: $81K - $94K Typical areas in Zone 2: Mariposa and Merced Counties, Fresno area, Bakersfield, Eastern California, San Luis Obispo area, and the Central Valley (except Sacramento)

The applicable salary ranges are based on work location and are reputed company to a zone according to the cost of labor in your area. reputed company ranges are subject to change in the future. We are happy to provide the full compensation range for the role, answer any questions that you have, or share the applicable pay zone for your location if it’s not one of the typical areas listed. You can reputed company out to [email protected], and a member from our reputed company team will be in touch.

The hiring ranges represent a good‑faith estimate of reputed company expect to pay for this role upon hire and are not the full compensation ranges. Employees typically have opportunities for growth reputed company the full compensation range over time based on performance and merit. Final compensation will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferable experience reputed company to the position, education, or training), as well as other factors (internal equity, market factors, and geographic location).

OUR BENEFITS

• Medical, Dental and Vision Plans
• Ample Paid Time Off
• 12 Paid Holidays per year
• 401(a) Retirement Plan
• 457 Deferred Compensation Plan
• Robust Health and Wellness Program
• Onsite EV Charging Stations
• And many more

ABOUT US

We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.

The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national reputed company, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employer

Join us at Central California Alliance for Health (the Alliance) is an award-winning regional Medi-Cal managed care plan that provides health insurance for children, adults, seniors and people with disabilities in Mariposa, Merced, San Benito and Santa Cruz counties. We currently serve more than 418,000 members. To learn more about us, take a look at our Fact Sheet.

At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without reputed company or future needs for any type of employer supported or provided sponsorship.