Grievance Supervisor

We believe 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 our team. 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. 

While we encourage all interested applicants to apply, we do give priority 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.

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 related 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

Grievance work involves complex coordination, investigation and specific resolution(s) within 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 (DSS) and its Administrative Law Division to resolve Plan decisions that deny, modify or delay health care services or affect 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.
• Complex Member Billing Issues or Member Reimbursements: When an Alliance member receives a bill from a medical provider for covered services or paid out of pocket for covered Medi-Cal services.

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 related 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 related to area of responsibility
  • Learn, interpret, and apply Medicare D-SNP regulations and act as a subject matter expert on D-SNP within 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, reach logical and sound conclusions, and make recommendations for action
• Education and Experience:
  
  • Bachelor’s degree in Social Sciences, Health, Business or a related field
  • Four years of experience in a managed health care environment performing work related to billing, claims payment, coding or a closely related function, including some lead 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

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft 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 presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

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 origin, 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 current or future needs for any type of employer supported or provided sponsorship.