Senior Manager, Clinical Appeals Grievances

Description and RequirementsThe Senior Manager, Clinical Appeals & Grievances provides strategic and operational leadership for the Clinical Appeals & Grievances function, ensuring timely, high-quality, and compliant review of clinical appeals and/or grievance cases. This role oversees day-to-day operations, leads internal teams, and partners with cross-functional leaders to optimize workflows, standardize processes, and drive continuous improvement. As a subject matter expert in Appeals & Grievances, the Senior Manager leverages data, performance metrics, and industry best practices to enhance operational efficiency, ensure regulatory compliance, and support organizational goals for quality, growth, and member satisfaction.Job DescriptionOversee daily operations, delegate work, and monitor productivity, quality and operational performanceEnsure Appeals and Grievances processes comply with all regulatory and organizational requirementsAssess staffing needs and support organizational design and workforce planning initiativesLead, coach, and develop individual contributors and people leaders to achieve performance and operational goalsProvide guidance on internal policies, procedures, and regulatory requirements.Standardize workflows and implement best practices to improve production, quality, compliance, and efficiencyPartner with leadership to establish and implement departmental goals, establish monthly goal review process and implement a plan of action for identified gapsOversee C2C Innovative Solutions, Fair Hearing, and External Appeal processes to ensure timely and complaint case managementManage vendor performance and ensure service levels and compliance expectations are achievedBuild and sustain collaborative relationships across departments to drive operational improvements and resolve process concernsAnalyze operational trends, identify performance gaps and implement corrective actionsPrepare and review operational reports and performance metric