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GENERAL DESCRIPTION OF POSITION The Manager, Grievance & Appeals is the primary point person responsible for the development and management of all grievance and appeal related activities and for providing a positive and professional experience for members and providers going through grievance or appeals processes. As the go-to person for grievances and appeals, this position interprets guidance from regulators, implements processes to ensure compliance, oversees the day-to-day operations of the grievance and appeals staff and represents the plan externally with providers, delegates and regulators in scheduled and ad hoc meetings, joint operating committee meetings, hearings and audits. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below. Read, interpret and implement all regulatory guidance related to the handling of appeals and grievances, including the Medicare Managed Care Manual, State and Federal contracts , APLs,DPLs and other memos that provide direction. Demonstrate a solid understanding of the appeals and grievance processes, including all regulatory and reporting requirements. Establish and document processes, policies, procedures and workflows to support compliant and timely handling of appeals and grievances. Create and implement any necessary corrective action plans to bring areas of non-compliance into compliance. Manage all grievance and appeals related reports ensuring accuracy and timeliness of submissions. Prepare case files and represent SCFHP in State Hearings or other escalated types of cases, including development of the Statement of Position and Independent Review Entity (IRE) case narratives. Act as the subject matter expert and initial point of contact for complex and escalated grievance and appeals cases for the department staff. REQUIREMENTS – Four-year degree in General Business, Law, Social Sciences or Health Care Administration, or related experience. Minimum two years management experience including direct supervisory experience of multiple staff, responsibility for hiring and performance management. Minimum three years of health plan operations experience, with demonstrated knowledge of health plan operations and the interactions between appeals and grievances, customer service, utilization management, claims and provider relations. Two years of experience working in grievances and/or appeals (including medical and pharmacy), or a closely related area of health plan operations. Knowledge of Medicare and Medicaid/Medi-Cal requirements.

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.