Appeals and Grievances Manager

CENTERLIGHT

. Lead daily operations of the appeals and grievances department, including intake, classification, assignment, investigation, resolution, documentation, and closure of participant and provider cases .

Posted 9/22/2026full-timeRemote • United StatesMid-LevelSenior💰 $95,000 - $105,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing appeals and grievances processes, ensuring compliance with CMS and state regulations, and leading teams in a healthcare setting. Proficient in data analysis, quality improvement, and staff development to enhance operational efficiency and participant satisfaction.

Highest-signal resume keywords

Appeals And Grievances ManagementRegulatory ComplianceTeam LeadershipData AnalysisQuality Improvement

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Case ManagementRoot-Cause AnalysisPerformance MeasurementGrievance ResolutionUtilization ManagementAdverse Determination ReviewPolicy DevelopmentAudit ReadinessProject ManagementStrategic Thinking

Soft Skills

Interpersonal CommunicationProblem-SolvingCoachingMotivational LeadershipAnalytical Skills

Tools & Technologies

Microsoft OfficeExcelWordPowerPointElectronic Health Records (EHR)

Industry Keywords

Managed CareHealthcare AdministrationQuality Assurance Performance Improvement (QAPI)Participant RightsConfidentiality

About the role

Key responsibilities & impact

Lead daily operations of the appeals and grievances department, including intake, classification, assignment, investigation, resolution, documentation, and closure of participant and provider cases
Supervise, coach, and evaluate A&G staff; establish performance expectations, provide feedback, support professional development, and address performance or workflow concerns
Plan staffing and assign workloads based on volume, urgency, complexity, competency, and regulatory deadlines
Maintain written processes for identifying, documenting, investigating, and resolving grievances and processing standard and expedited appeals
Monitor pending cases, aging, due dates, extensions, expedited requests, adverse determinations, and closure documentation
Review complex, high-risk, sensitive, or escalated cases and determine next steps using policy and regulatory guidance
Coordinate fact-finding with clinical leaders, interdisciplinary teams, claims, provider relations, transportation, home care, compliance, legal counsel, delegated entities, and external providers
Ensure appeals are reviewed by appropriately credentialed and impartial reviewers
Review and approve acknowledgments, information requests, adverse determination notices, resolution letters, and other communications
Ensure case records are complete, accurate, confidential, and maintained according to retention and audit requirements
Develop and maintain A&G/SDR policies, procedures, workflows, templates, job aids, and training materials with the Call Center Director
Conduct quality audits and inter-rater reliability reviews; develop corrective action plans and monitor improvement
Analyze A&G/SDR data to identify trends, systemic issues, disparities, root causes, and process improvement opportunities
Prepare and present weekly, monthly, quarterly, annual, and committee reports
Integrate grievance and appeal findings into the organization’s QAPI program and monitor improvement actions
Support audits, regulatory reviews, submissions, records requests, surveys, and corrective action responses
Serve as the department escalation point and educate staff on recognizing, receiving, documenting, and routing grievances and appeals
Promote participant rights, culturally and linguistically appropriate communication, confidentiality, non-retaliation, and participant-centered resolution
Establish and monitor service levels, staff performance, and quality measures
Adhere to organizational policies and perform other assigned duties

Requirements

What you’ll need

Bachelor’s degree in health care administration, nursing, public health, business, social work, or a related field required; relevant additional experience may be considered in lieu of education
Minimum of 3+ years of progressive responsible experience in appeals, grievances, complaints, utilization management, claims, compliance, quality, or related managed care or health care functions
Supervisory or team leadership experience
Working knowledge of applicable CMS and state requirements governing participant rights, grievances, service determinations, appeals, adverse determinations, confidentiality, regulatory reporting, and audit readiness
Knowledge of QAPI principles, root-cause analysis, corrective action, and performance measurement preferred
Proficiency with computers, especially Microsoft Office, Excel, Word, and PowerPoint
Experience using Electronic Health Records (EHR), case management, reporting, or database systems
Experience working for or in long-term care or a managed care setting
Ability to lead and motivate others through change, develop project plans, and manage competing deadlines
Independent judgment, strategic thinking, problem-solving, and analytical skills
Strong written, verbal, and interpersonal communication skills
Proficiency in training and staff development preferred
Ability to meet stated physical requirements, including standing, sitting, lifting/pushing/pulling up to 50 pounds, bending/squatting, walking/climbing, fine motor skills, visual requirements, audio processing, speaking, and cognitive decision-making abilities

Benefits

Comp & perks

Work from Home
Full-time schedule with 40 weekly hours
Equal opportunity employment and reasonable accommodation for individuals with disabilities