Supervisor Grievance and Appeals

• Supervisor Grievance and Appeals

• CalOptima

• 505 City Pkwy W, Orange, California92868United States View Map

Job Description

Supervisor Grievance and AppealsCalOptimaJoin Us in this Amazing OpportunityThe Team You'll JoinWe 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 OpportunityWe are hoping you will join us as a Supervisor Grievance and Appeals and help shape the future of healthcare where you'll be an integral part of our GA - Provider Disputes 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 Supervisor Grievance and Appeals will be responsible for the daily operations of Grievance and Appeals Resolution Services (GARS). You will supervise staff and provide the necessary training and guidance needed. You will work closely with the trainer, departmental audit team and business analyst to identify training opportunities, patterns and trends from the complaints and opportunities to streamline and improve processes. You will stay up to date on the latest information about CalOptima Health's member benefits and regulatory changes and ensure adherence to established policies and procedures regarding the appeals and grievance process. Together, we are building a stronger, more equitable health system.Your Contributions To the Team:- 50% - Supervisory Functions- Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.- Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.- Provides guidance and supervises the day-to-day activities of the team to ensure compliance with company policies and regulatory requirements.- Assists in the hiring process and provides ongoing staff training as needed.- Supervises and supports staff performance, including performance measurement, evaluation and professional development.- Facilitates one-on-one meetings with staff to review monthly progress regarding performance.- 45% - Program Oversight- Manages case inventory to ensure regulatory and departmental standards are met.- Handles escalated member or provider cases/calls as needed.- Provides prompt communication to staff and conducts monthly unit meetings to review changes to programs or training issues.- Collaborates with leadership and staff to set work performance standards and determine assignment priorities.- Evaluates departmental work procedures to identify inefficiencies and areas for improvement.- Collects and analyzes relevant information to resolve process-related issues, recommends updates and communicates actionable solutions to management for implementation.- 5% - Completes other projects and duties as assigned.Do You Have What the Role Requires?- Bachelor's degree PLUS 1 year of experience of health care management experience, preferably in a managed care environment in related areas of responsibility of utilization management, quality management, customer service or grievances and appeals 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.You'll Stand Out More If You Possess the Following:- 2 years of supervisory or lead work experience.- Health Maintenance Organization (HMO), Medi-Cal/Medicaid, Medicare and Health Services experience.- Experience in Medi-Cal or Medicare regulatory guidelines for Appeals and Grievances.- Experience with Medi-Cal and Medicare claims billing guidelines (i.e., Health Care Financing Administration [HCFA] 1500, Universal Billing 92 [UB] 92, Coordination of Benefits [COB], including Current Procedural Terminology [CPT], ICD-10 and Healthcare Common Procedure Coding System [HCPCS] codes).- Bilingual in English and in one of CalOptima Health's defined threshold languages (Arabic, Chinese, Farsi, Korean, Russian, Spanish, Vietnamese).What the Regulatory Agencies Need You to Possess?- NAYour 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 poundsWays We Are Here For You- You'll enjoy competitive compensation for this role.- Our current hiring range is: Pay Grade: 312 - $84,092 - $134,548 ($40.43 - $64.6865).- 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 October 6, 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 YouYour 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 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/9851004je-f91eec5de941401593caa05edd7f4a47

CalOptima

Our motto and programs

“Better. Together.” is our motto, and it means that by working together, we can make things better - for our members and community. As a public agency, CalOptima was founded by the community as a County Organized Health System that offers health insurance programs for low-income children, adults, seniors and people with disabilities. As Orange County’s single largest health insurer, we provide coverage through four major programs:

Medi-Cal

California’s Medicaid Program for low-income children, adults, seniors and people with disabilities, offering comprehensive health care coverage

OneCare Connect Cal MediConnect Plan

Medicare-Medicaid Plan that combines Medicare and Medi-Cal benefits and adds worldwide emergency care, dental care, vision care and transportation to medical services at no extra cost

OneCare (HMO SNP)

Medicare Advantage Special Needs Plan for seniors and people with disabilities who qualify for both Medicare and Medi-Cal

Program of All-Inclusive Care for the Elderly

PACE for frail older adults, providing a full range of health and social services so seniors can remain living in the community

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Employer Profile

• Supervisor Grievance and Appeals

• CalOptima
• 505 City Pkwy W, Orange, California92868United StatesView Map

• Posted:Sep 25, 2026

• Location:505 City Pkwy W, Orange,California

• Human and Social Services
• Public Health

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