Assistant Director Health Plan Appeals Grievances

An amazing position has recently opened for an Assistant Director to oversee the Appeals and Grievances Operations program for this California Coast health plan network. Join a tenured and experienced leadership team, and help lead this expanding and popular patient-centered network forge the path towards great patient outcomes and efficient operations.

Having received top honors and awards for both clinical and administrative operations in Central California, the health systems that this plan support are highly regarded in the region. Offering coverage on a full range of services, to a full range of populations, the Appeals and Grievances Assistant Director will help the system continue to build those service offerings and increase member access to the services they need.

Reporting to the Sr. Director of Health Plan Operations, the Assistant Director of Appeals will oversee leaders from Claims Management, Enrollment, Medical Management, and the Call center. This person will play an important role in keeping the health plan’s operations running smoothly and in accordance with regulatory requirements.

The Assistant Director’s primary responsibility will be managing the process of First Tier Appeals and Grievances, as well as overseeing the G&A process through escalation. Overseeing a team of Appeals specialists, this person will provide direction, training, and confidence to the department. The Assistant Director will take responsibility for properly recording and documenting interactions, investigating claims, and and evaluating performance against goals set my senior leaders.

Another large part of this role will be monitoring and maintaining regulatory compliance with a broad range of local, state, and federal regulatory frameworks. Strong experience with CMS, IRS, HIIPAA, ACA, COBRA, and the Knox-Keene Act will be a great foundation as further policy knowledge develops. Furthermore, familiarity with the health care industry, exchanges, Medicare Advantage regulations, and audit execution will allow the Assistant Director to excel.

Living and working close to the San Francisco Bay Area, you’ll discover something wonderful for every mood. When you’re feeling fancy, you can go to San Francisco for an art exhibit and a live concert, or a short drive north lands you California Wine Country, where you’ll be confronted with amazing cuisine and the finest vin in America. When the Appeals and Grievances Assistant Director is feeling energetic, you’ll find hundreds of short and long hikes, bike rides, and boat trips. With some of the nation’s best schools, most diverse cultures, and highest qualities of life, the area around San Francisco is a great place to put down roots.

This Assistant Director will play a large role in the maintaining the operations that keep this Health Plan running smoothly. You’ll manage a team who works directly with patients, you’ll liaise with a diverse array of healthcare providers, and you’ll support the strategic mission of this network. You, in turn, will be supported by a generous benefits package, and a competitive compensation.