Sr Manager, Grievance & Appeals Resolution Services (Sr. Manager II)

Sr Manager, Grievance & Appeals Resolution Services (Sr. Manager II)

CalOptima

Join Us in this Amazing Opportunity

The Team You'll Join

We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all.

More About the Opportunity

We are hoping you will join us as a Sr Manager, Grievance & Appeals Resolution Services (Sr. Manager II) and help shape the future of healthcare where you'll be an integral part of our Grievance & Appeals team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Partial Telework.

• If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum.

The Sr Manager II (Grievance & Appeals Resolution Services) will provide oversight and leadership to the Grievance and Appeals Resolution Services (GARS) department. You will maintain knowledge of all new regulatory guidelines impacting GARS for all CalOptima Health programs. You will ensure full compliance with all state and federal laws, regulations, rules, and contract requirements as set forth by the Department Health Care Services (DHCS), Department of Managed Health Care (DMHC), the Centers for Medicare and Medicaid Services (CMS), and any other governmental entities with regulatory authority. This position requires demonstrated leadership capabilities, knowledge and understanding of member and provider grievance and appeals operations processes, protocols, as well as foundational audit and training knowledge and experience. Together, we are building a stronger, more equitable health system.

Your Contributions To the Team:

• 50% - Leadership Function

• Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

• Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.

• Hires, manages, trains, supports, develops and evaluates direct reports.

• Directs work assignments, measures results and initiates personnel actions.

• Oversees staff assignments to ensure effective allocation of resources to ensure state and federal regulations are met and establishes production standards for the department.

• Assists the director on key initiatives, including special review, departmental initiatives and strategic planning efforts.

• Assists department leadership in the management of critical business risks by communicating best practices, promoting process improvement, and monitoring remediation activities.

• Collaborates regularly with all CalOptima Health's staff levels and external contacts with regulatory agencies, health networks, community-based organizations and medical groups

• Leads, coordinates, and monitors policy and procedural changes and maintains the process for revision and implementation that supports plan regulatory compliance.

• Co-leads Grievance and Appeals quarterly committee meetings and attends all internal committees within the CalOptima Health organization to report activities and trends.

• Maintains current knowledge of regulatory requirements pertinent to grievance and appeals including DHCS, CMS, DMHC, and National Committee for Quality Assurance (NCQA).

• Participates in all state and federal regulatory audits as the business lead as it relates to grievance and appeals.

• 45% - Program Oversight

• Ensures that regulatory protocols and rules for the grievance and appeals process are followed.

• Manages and leads all operational and other non-compliance audits.

• Collaborates across all department areas within GARS, focusing on process improvements and training needs based on internal and external audit outcomes.

• Acts as a trusted advisor by fostering strong relationships with internal business areas and external engagement partners.

• Reviews and analyzes member and provider appeals, grievances, and State Fair Hearing data along with audit results to improve root causes of member dissatisfaction and implements action plans and workflows for improvement to achieve member/provider satisfaction and operational effectiveness when assigned to member grievances and appeals.

• Designs and implements resource and capacity management strategies to maximize efficiencies in grievance and appeals handling, and audits and training.

• Leads the development of a grievance and appeals training program.

• Proactively communicates with and advises key leadership regarding process improvements, project status, risks and issues.

• Performs audits and oversight to monitor compliance with policies and regulatory requirements, as well as ensure process and operational efficiency.

• 5% - Completes other projects and duties as assigned.

Do You Have What the Role Requires?

• Bachelor's degree PLUS 5 years of healthcare grievance and appeals experience in a managed care organization required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

• 4 years of leadership experience in a healthcare company required.

• Previous state or federal healthcare audit experience required.

You'll Stand Out More If You Possess the Following:

• Health Maintenance Organization (HMO), Medi-Cal/Medicaid, Medicare and insurance experience or relevant government client or public service experience.

• Current, unrestricted Licensed Vocational Nurse (LVN) OR Registered Nurse (RN) License to practice in the State of California.

What the Regulatory Agencies Need You to Possess?

• N/A

Your Knowledge & Abilities to Bring to this Role:

• Develop rapport and establish and maintain effective working relationships with CalOptima Health's leadership and staff and external contacts at all levels and with diverse backgrounds.

• Work independently and exercise sound judgment.

• Communicate clearly and concisely, both orally and in writing.

• Work a flexible schedule; available to participate in evening and weekend events.

• Organize, be analytical, problem-solve and possess project management skills.

• Work in a fast-paced environment and in an efficient manner.

• Manage multiple projects and identify opportunities for internal and external collaboration.

• Motivate and lead multi-program teams and external committees/coalitions.

• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Your Physical Requirements (With or Without Accommodations):

• Ability to visually read information from computer screens, forms and other printed materials and information.

• Ability to speak (enunciate) clearly in conversation and general communication.

• Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.

• Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.

• Lifting and moving objects, patients and/or equipment 10 to 25 pounds

Ways We Are Here For You

• You'll enjoy competitive compensation for this role.

• Our current hiring range is: Pay Grade: 317 - $132,969 - $212,751 ($63.93 - $102.2841).

• The final salary offered will be based on education, job-related knowledge and experience, skills relevant to the role and internal equity among other factors.

• This position is approved for Partial Telework (**If the position is Telework, it is eligible in California only**)

• A https://www.caloptima.org/en/careers#benefits

• CalPERS pension program and additional retirement packages.

• Additional benefits and perks including:

• A generous PTO program

• A quality work life balance

• Various wellness programs

• Tuition Reimbursement

• Professional development opportunities

• Career development opportunities

• Flexible scheduling

• And the satisfaction of knowing your work directly impacts and improves healthcare access for thousands of individuals and families.

Our Work Environment:

If located at the 500, 505 Building or a remote work location:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.

• There are no harmful environmental conditions present for this job.

• The noise level in this work environment is usually moderate.

If located at PACE:

• Work is typically indoors in a clinical setting serving the frail and elderly.

• There may be harmful or hazardous environmental conditions present for this job.

• The noise level in this work environment is usually moderate to loud.

If located in the Community:

• Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.

• Employee will occasionally work outdoors in varied temperatures.

• There may be harmful or hazardous environmental conditions present for this job.

• The noise level in this work environment is usually moderate to loud.

Why Join Us?

We believe that diverse perspectives drive innovation. Each employee brings a unique perspective to the overall team and we value everyone's input and we are committed to creating an inclusive environment where you and every team member can thrive while making a meaningful impacts on our community members. Our team reflects and represents the communities we serve, and we welcome candidates from all backgrounds who share our commitment to accessible, quality healthcare.

What's Your Next Step?

All Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. Do NOT miss out. If you want to join our team, the deadline for the first review of applications is February 11, 2026 at 9:00 PM (PST). We are encouraging you to apply early. If you apply after the first review date, your application is not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date.

Our Commitment to You

Your application and resume will be reviewed by a dedicated recruiter to this position. If your experience matches what we need, we will reach out to you to discuss the next steps. The selection process may include, but is not limited to, a skills assessment, phone screen and interview.

If you make it through the steps above and are selected for this exciting role, you will be required to undergo a reference and a background check (to include a conviction record) and if applicable also pass a drug screening and/or a post-offer pre-employment medical examination (for specific positions) If you are an Internal CalOptima Health applicant, please apply through the internal portal on InfoNet.

We will make sure to keep you updated through each step of the process on your candidate portal. Please make sure to watch for updates on your candidate portal and you emails which will be sent to the email address you listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process.

CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together.

CalOptima Health is an equal opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation at (714) 246-8400 if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

To apply, please visit: https://apptrkr.com/6885785

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