Mgr Appeals

Position Summary

The Manager of Medicare Appeals & Grievances is responsible for the end‑to‑end operational, regulatory, and quality oversight of Medicare Advantage (Part C) and Medicare Part D appeals and grievance activities. This role ensures compliance with CMS regulations, NCQA standards, and contractual requirements, while driving operational efficiency, audit readiness, and a positive member experience.

The Manager provides direct leadership to non‑clinical staff, oversees daily inventory management, ensures timely and accurate determinations, and partners closely with Compliance, Quality, Legal, Utilization Management, Delegation Oversight, and external vendors.

Key Responsibilities

Operational Leadership

·       Manage day‑to‑day operations of Medicare Appeals & Grievances teams, including staffing, workload distribution, case assignment, escalations, and performance monitoring.

·       Ensure appeals and grievances are processed accurately and resolved within CMS‑mandated timeframes for all case types, including standard, expedited, and Part D appeals.

·       Oversee intake, investigation, determination, notification, and effectuation processes across appeals and grievances.

·       Serve as the primary escalation point for complex, high‑risk, or sensitive Medicare cases.

Regulatory & Compliance Oversight

·       Assume overall accountability for maintaining workflows that comply with CMS Medicare Advantage and Part D regulations, including documentation, notification, and member rights requirements.

·       Work collaboratively with Compliance Analysts to monitor regulatory updates and ensure translation of changes into operational procedures, training materials, and system updates.

·       Partner with internal and external Compliance and Quality teams to prepare for and respond to CMS program audits, market conduct exams, and NCQA audits.

·       Lead corrective action plans and remediation efforts resulting from audits, quality reviews, or regulatory findings.

Quality & Performance Management

·       Track and report key performance indicators, including timeliness, accuracy, volumes, overturn rates, grievance trends, and audit outcomes.

·       Oversee quality review activities for appeal and grievance files, identify error trends, and implement targeted coaching and process improvements.

·       Conduct root cause analysis for repeat errors, adverse audit findings, or member dissatisfaction and drive sustainable solutions.

·       Ensure decision letters and case documentation meet CMS and NCQA content and clarity requirements.

Team Leadership & Development

·       Lead, coach, and develop supervisors, team leads, and specialists.

·       Set clear performance expectations aligned with regulatory and organizational goals.

·       Support onboarding, training, and ongoing competency development for Medicare Appeals & Grievances staff.

·       Foster a culture of accountability, compliance, collaboration, and continuous improvement.

Vendor & Cross‑Functional Collaboration

·       Provide oversight of delegated and vendor‑supported Medicare appeals and grievance functions, ensuring adherence to contractual and regulatory standards.

·       Collaborate with Utilization Management, Care Management, Provider Relations, Customer Service, Delegation Oversight, and Legal to resolve systemic issues impacting appeals and grievances.

·       Participate in cross‑functional initiatives related to system enhancements, automation, and process optimization.