Director, Grievance and Appeals – Preferred Experience in Managed Care

CareSource

. Oversee appeals and grievance processes .

Posted 11/1/2026full-timeRemote • United StatesLead💰 $113,000 - $197,700 per yearWebsite

Core Competencies

Role fit

Core Competencies

Use this summary to align your resume positioning with the role.

Demonstrates expertise in managing appeals and grievance processes within a healthcare operational environment, ensuring compliance with regulations while enhancing performance and operational efficiency. Strong analytical and problem-solving capabilities are essential for identifying process improvements and minimizing risks.

Highest-signal resume keywords

Management ExperienceManaged Care ExperienceHealthcare Operational LeadershipAnalytical SkillsCustomer Service Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Process DesignPolicy ImplementationData AnalysisFiscal ManagementPerformance Improvement

Soft Skills

Strong Communication SkillsProblem-Solving SkillsInterpersonal SkillsDecision-Making Skills

Tools & Technologies

Windows Environment

Industry Keywords

Appeals ProcessGrievance ProcessRegulatory ComplianceOperational ManagementHealthcare

About the role

Key responsibilities & impact

Oversee appeals and grievance processes
Direct efficient operational management of the appeals and grievance function, emphasizing execution, outcomes, continual improvement and performance enhancement
Design and implement processes, policies, training and procedures to ensure compliance with regulations
Address below-standard performance and implement mechanisms to improve performance
Track and trend preventable appeals and grievances and present findings to Operations leadership
Minimize legal and financial risk while protecting the interests of members and providers
Identify the need for in-house legal involvement on sensitive cases
Coordinate with plan attorneys on litigated cases and help oversee case preparation and research
Provide fiscal management and support, including operating budgets, forecasts and variance reporting
Ensure appropriate systems and technology support compliance, quality and operational efficiency
Analyze data to identify and implement process improvements
Coordinate grievance and appeal committee meetings
Establish and maintain relationships with internal partners
Perform other job duties as requested

Requirements

What you’ll need

Bachelor of Science/Arts (BA/BS) or equivalent years of work experience is required
Minimum of five (5) years of management experience is required
Managed care experience is required
Direct leadership experience in a Healthcare operational G&A environment is required
Master’s degree is preferred
Senior management experience is preferred
Customer service skills with the ability to interact professionally and effectively with members, providers, internal business areas and colleagues
Strong analytical skills with the ability to create reports and interpret operational, utilization and financial data
Proven problem-solving skills with the ability to identify root causes and develop implementable solutions
Computer proficiency with knowledge and experience in a Windows environment
Maintain regulatory knowledge for compliance
Strong written and verbal communication skills
Ability to work in a fast-paced environment
Decision-making and problem-solving skills
No licensure or certification required

Benefits

Comp & perks

Bonus tied to company and individual performance may be available
Substantial and comprehensive total rewards package
Employee total well-being support