Appeals & Grievances Manager

Appeals & Grievances Manager

Harbor Health

POSITION OVERVIEW

We are seeking an experienced and detail-oriented Appeals & Grievances (A&G) Manager to lead and optimize our health plan complaint, grievance, and appeals operations ensuring all cases are resolved in a timely, fair, and compliant manner that upholds regulatory standards and exceeds member expectations. This fully remote leadership role is accountable for managing a dedicated fully remote team, driving continuous process improvement across cross-functional departments, mitigating regulatory and operational risk, and maintaining the highest standards of transparency, fairness, and customer service. By aligning the grievance, appeal, and complaint processes with evolving federal and state regulatory requirements, the Manager safeguards organizational compliance while enhancing member satisfaction and operational efficiency.

The ideal candidate brings deep operational knowledge of state and federal regulatory compliance, a track record of running high-performing resolution teams, and hands-on familiarity with core administrative and grievance management platforms.

POSITION DUTIES & RESPONSIBILITIES

Operational Leadership & Case Adjudication

• Oversee day-to-day intake, investigation, processing, and resolution of member and provider complaints, grievances, and appeals across our Texas fully insured Individual & Family Plan (IFP/Marketplace) and large group (25+ employees) commercial products.

• Ensure strict adherence to statutory turnaround times (standard and expedited/urgent) mandated by regulators.

• Partner with Medical Directors and Clinical Review teams to facilitate timely clinical determinations and external independent review organization (IRO) submissions.

• Review complex case files and mentor/coach staff on how to draft clear and compliant written resolution notices.

Compliance & Regulatory Oversight

• Maintain audit readiness by establishing comprehensive standard operating procedures (SOPs), quality control workflows, and monitoring mechanisms.

• Lead department readiness for DOI market conduct examinations, internal audits, and accreditation surveys (e.g., NCQA).

• Track regulatory shifts across Commercial and Exchange markets, translating updates into operational policies and training materials.

• Maintain a documentation focus with drafting/reviewing/approving process flow documentation and audit-ready documentation standards.

Systems, Process Optimization & Data Analysis

• Leverage core systems to streamline intake from call center escalations, automate workflows, and track end-to-end case disposition.

• Analyze root-cause grievance and complaint data to detect operational failure points, billing issues, network adequacy gaps, and authorization friction points.

• Build executive-level dashboards tracking turnaround time (TAT) compliance, overturn/upheld rates, complaint categories, and audit sample accuracy.

People Leadership & Cross-Functional Collaboration

• Supervise, mentor, and evaluate A&G specialists and analysts in a 100% remote work environment.

• Work closely with Member Services/Call Center leadership, Claims Operations, Utilization Management, and Legal/Regulatory affairs to resolve systemic member and provider friction.

• Develop and deliver comprehensive A&G training across Harbor Health departments regarding critical A&G topics to promote compliance and support audit-ready operations.

DESIRED PROFESSIONAL SKILLS & EXPERIENCE

Required Experience & Education

• Minimum of 5–7 years in managed care or health plan operations, with at least 3 years directly focused on Appeals & Grievances and complaints handling.

• Minimum of 2–3 years in a team lead, supervisory, or managerial capacity managing remote staff.

• Deep knowledge of federal and state appeal regulations, external review mandates, and grievance classification taxonomies.

Preferred Qualifications

• Bachelor’s degree in Healthcare Administration, Business, Public Health, or a related field (or equivalent operational experience).

• Hands-on experience utilizing Axiscore modules for claims adjudication, customer service/call center logging, or appeals and complaints tracking.

• Demonstrated expertise in Commercial health plans, including Large Group and Individual & Family Plans (ACA/Marketplace).

• Prior experience managing appeals for clinical denial workflows alongside contracted Independent Review Organizations (IROs).

• Relevant industry certifications (e.g., CHC, HIA, or certified compliance professional credentials).

WHAT WE OFFER

• Fully remote work environment

• Competitive salary and benefits package

• Generous PTO

• 10 paid holidays

• Medical, Dental, and Vision Insurance

• 401(k) Investment Plan

• Professional development and growth opportunities

• A transparent and unique culture

• Collaborative and dynamic work environment

COMPANY OVERVIEW

At Harbor Health, we're transforming healthcare in Texas through collaboration and innovation. We're seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you're ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!

EQUAL EMPLOYMENT OPPORTUNITY

Harbor Health is an Equal Opportunity Employer. We celebrate diversity and are committed to building an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic.