Manager Grievances - Appeals, And Complaints

Founded in 1977 as the Senior Care Action Network, SCAN began with a simple but radical idea: that older adults deserve to stay healthy and independent. That belief was championed by a group of community activists we still honor today as the “12 Angry Seniors.” Their mission continues to guide everything we do.

Today, SCAN is a nonprofit health organization serving more than 500,000 people across Arizona, California, Nevada, New Mexico, Texas, and Washington, with over $8 billion in annual revenue. With nearly five decades of experience, we have built a distinctive, values-driven platform dedicated to improving care for older adults.

Our work spans Medicare Advantage, fully integrated care models, primary care, care for the most medically and socially complex populations, and next-generation care delivery models. Across all of this, we are united by a shared commitment: combining compassion with discipline, innovation with stewardship, and growth with integrity.

At SCAN, we believe scale should strengthen—not dilute—our mission. We are building the future of care for older adults, grounded in purpose, accountability, and respect for the people and communities we serve.

The Job

The Manager Grievances, Appeals, and Complaints leads the strategic oversight and daily operations of the organization's grievance, appeal and complaint program, ensuring all cases are resolved in a timely, fair, and compliant manner that upholds regulatory standards and exceeds member expectations.

This role is accountable for managing dedicated teams, 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 grievance, appeal and complaint processes with evolving federal and state regulatory requirements, the Manager safeguards organizational compliance while enhancing member satisfaction and operational efficiency.

You Will

• Strategic Department Leadership: Lead, manage, and oversee the day-to-day operations and productivity of the Grievance and Appeals Department, ensuring alignment with organizational goals, vision, and strategic objectives while maintaining high-volume case throughput and service level agreements. 
• Regulatory Compliance Management: Ensure full compliance with all applicable federal and state regulatory standards, including but not limited to CMS (Medicare Part C and Part D), DMHC, DHCS, and other governing bodies, by establishing processes for ongoing monitoring, staff training, and proactive remediation of identified non-compliance areas. 
• Workflow and Process Optimization: Develop, implement, and continuously improve workflows, systems, tools, and monitoring processes to ensure timely completion of all grievance, appeal, and complaint functions within required regulatory timeframes, driving operational efficiency and quality outcomes. 
• Team Management and Staff Development: Recruit, select, orient, train, and develop department staff, acting as the first-line resource for problem-solving and performance management, ensuring proper staffing levels (including temporary staffing), and fostering a culture of teamwork, accountability, and professional growth. 
• Cross-Functional Stakeholder Collaboration: Partner with cross-functional teams across legal, compliance, customer service, operations, and clinical leadership to address complex grievance and appeal issues, resolve escalations, and drive integrated process improvements that align with organizational priorities. 
• Data Analytics and Executive Reporting: Develop, analyze, and present department metric reporting on productivity, efficacy, and compliance trends to senior leadership, conducting root cause analysis for recurring issues and developing data-driven action plans to prevent recurrence and improve outcomes. 
• Strategic Policy Recommendations: Analyze grievance and appeal trends, recurring issues, and regulatory developments to recommend policy and procedure changes to senior management, ensuring the organization proactively adapts to emerging compliance requirements and operational challenges. 
• Subject Matter Expertise and Committee Representation: Function as the department's subject matter expert, representing the Grievance and Appeals function at assigned internal and external committees, regulatory interfaces, and cross-departmental forums to ensure two-way communication and organizational alignment. 
• Clinical Case Review Coordination: Interface directly with the Medical Director, Pharmacists, and clinical leadership to ensure quality case review, accurate case classification, and appropriate escalation of Medicare Part C and Part D cases in accordance with department policies, procedures, and regulatory standards.
• External Stakeholder and Regulatory Engagement: Engage with external stakeholders, including regulatory bodies, healthcare providers, and labor representatives, to resolve complex grievances and appeals, monitor adherence to labor agreements and regulatory mandates, and uphold fairness and transparency throughout the resolution process. 
• We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
• Actively support the achievement of SCAN’s Vision and Goals. 
• Other duties as assigned.

Your Qualifications

Required Experience:

• Bachelor's Degree or equivalent experience in Healthcare Administration, Business Administration, Nursing, Public Health, or a related field, or equivalent combination of education and experience.
• 5+ years of relevant Medicare Advantage experience, including at least 2–3 years specifically in Medicare Advantage appeals and grievances operations.
• 2–3 years of demonstrated management experience leading teams in a large-scale, high-volume production operation.
• Working knowledge of guidelines and regulations relevant to Grievance and Appeals, including Medicare, Medi-Cal, DMHC, DHCS, and NCQA Guidelines Strong strategic planning, critical thinking, and leadership skills.
• Excellent presentation skills, group motivation, and supervisory skills.
• Proven ability to analyze data, identify performance gaps, and execute data-driven solutions to elevate operational outcomes.
• Proficiency with Microsoft Office Suite and case management or grievance tracking systems

Preferred Experience:

• Graduate or Advanced Degree or equivalent experience Healthcare Administration, Business Administration, Public Health, or a related field.
• LCSW, or RN Clinical License preferred 
• 5+ years of experience in medical management, change management, and/or organizational leadership.
• Strong knowledge of medical group/IPA operations, integrated delivery systems, and health plan structures.
• Operational experience in both rural and metropolitan markets, with demonstrated ability to identify market-specific performance gaps and design targeted solutions.
• Proven skills with advanced data analytics and the ability to design programs based on trend analysis and performance data inquiry.
• Experience presenting to senior leadership, regulatory bodies, and external stakeholders on grievance and appeals performance metrics.
• Experience with CMS audit preparation and response, including CAP submissions and corrective action plan management.

What's in it for you?

• Base salary range: $125,400 to $150,000 per year
• Work Mode: Mostly Remote
• An annual employee bonus program
• Robust Wellness Program
• Generous paid-time-off (PTO)
• Eleven paid holidays per year, plus 1 floating holiday, plus 1 birthday holiday
• Excellent 401(k) Retirement Saving Plan with employer match and contribution
• Robust employee recognition program
• Tuition reimbursement
• An opportunity to become part of a team that makes a difference to our members and our community every day!

We're always looking for talented people to join our team!  Qualified applicants are encouraged to apply now!

At SCAN we believe that it is our business to improve the state of our world. Each of us has a responsibility to drive Equality in our communities and workplaces. We are committed to creating a workforce that reflects our community through inclusive programs and initiatives such as equal pay, employee resource groups, inclusive benefits, and more.

SCAN is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

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Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)