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Job Summary

As the Supervisor, Appeals and Grievances you will oversee daily operations, staffing, and performance for a remote team of 15 Appeals & Grievance Specialists, Administrator, and Team Leads supporting our Pennsylvania Medicaid business. This role ensures that all provider appeals and grievance cases are processed accurately, timely, and in full compliance with applicable federal, state, and accreditation standards (CMS, NCQA, URAC, and state regulations). In addition, you will ensure collaboration between team members and leadership, coordinate workflow, maintain quality standards, monitor compliance metrics, and promote a culture of accountability and professional growth.

Work Arrangement

+ Remote- must be near Philadelphia for meetings

+ Monday through Friday from 8a EST to 5p EST

Responsibilities

+ **Leadership and Staff Management**

+ Supervise daily activities of assigned Appeals & Grievance staff, including scheduling, workload distribution and case prioritization

+ Provide ongoing coaching, performance feedback, and mentoring to develop Associate competencies

+ Serve as the first line of escalation for complex cases, providing subject matter expertise and decision support

+ **Operational Oversight**

+ Monitor daily inventory levels, turnaround times, and productivity metrics to ensure operational goals are met

+ Review and approve case documentation and correspondence for completeness, accuracy, and compliance

+ Ensure all appeals and grievance activities adhere to departmental policies, and standard operating procedures (SOPs), and regulatory requirements

+ Assist in the development and revision of procedures and workflow documentation to improve efficiency and accuracy

+ **Compliance & Quality**

+ Maintain departmental compliance with all regulatory requirements (CMS, NCQA, URAC, and state specific regulations)

+ Conduct routine case audits and quality reviews; document findings and implement corrective actions

+ Partner with Compliance and Quality departments to prepare for internal and external audits

+ **Reporting & Communication**

+ Track and report on key operational metrics, including productivity, accuracy, and compliance indicators

+ **Cross-Functional Collaboration**

+ Coordinate with Claims, Utilization Management, Member Services, Legal, and Compliance to ensure Consistent resolution of appeals and grievances

Education and Experience

+ Associate Degree in Health Administration, Business, or related field.

+ Preferred Experience Level (if different from minimum required): Knowledge of medical terminology, benefit interpretation, and regulatory processes preferred. Prior experience working with CMS, Medicaid, or state-regulated appeals processes preferred.

+ Minimum of 3 years of experience leading a team of clinical and non clinical staff

+ Minimum of 5 years experience in healthcare operations, managed care, compliance, or grievance/appeals coordination

+ Demonstrated experience overseeing complex or escalated cases within a managed care organization.

Skills and Abilities

+ Proven leadership and people management skills

+ Proficiency in Microsoft Office Suite (Word, Excel, Outlook, etc.)

+ Demonstrated knowledge of CMS, NCQA, and state-specific appeals and grievance requirements

+ Strong analytical, investigative, and documentation abilities

+ Excellent written and verbal communication

+ Ability to manage multiple priorities with accuracy in a fast-pace environment

+ Customer service mindset and professional demeanor

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com .

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.