Grievance & Appeals Manager
$85,000–$95,000 year
On-siteOklahoma, United States
Job Summary
Lead and manage all activities of the Grievance & Appeals department, ensuring grievances, appeals, and provider disputes are processed accurately within regulatory and contractual timelines. Monitor federal, state, and client changes impacting operations, lead root cause analysis activities, and develop corrective action strategies with business leaders. Evaluate workflows for existing and new health plan partnerships, create audit universes and case files, and serve as the primary presenter during internal and external audits. Develop performance reports, trend analyses, and regulatory insights for leadership, clients, and auditors while managing administrative support for Quality Management committees. Respond to regulatory inquiries and filings, including Evidence of Coverage documents and benefit updates. Work across departments to influence strategic initiatives and support executive leadership in driving operational excellence and compliance.
Required Qualifications
- Bachelor's degree preferred
- Minimum 5 years of experience in health insurance, preferably within dental insurance
- Minimum 3 years of experience in grievance and appeals, healthcare law, dental law, or a related regulatory environment
- Minimum 2 years of leadership experience managing cross-functional operations, including hiring, training, coaching, and performance management
- Minimum 6 years of overall relevant professional experience
- Strong collaborative leadership style
- Excellent verbal and written communication skills
- Effective presentation and facilitation abilities
- Proficiency with Microsoft Office applications
- Ability to analyze complex situations and make sound business decisions
- Strong organizational skills with the ability to manage multiple priorities simultaneously
- Demonstrated ability to work independently while contributing as a key member of a team
- Professional presence with the ability to build confidence and trust across stakeholder groups
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