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Healthfirst Manager, A&G Quality in Lake Mary, Florida


The Manager of Appeals & Grievances Quality drives the execution and oversight of A&G operations quality including intake performance, case development and universe validation.

This role works closely with multiple leaders in the organization to identify priority focus areas for Appeals & Grievances, to standardize and optimize processes, and to communicate performance to multiple stakeholders. In tandem with these efforts, this individual will oversee A&G quality programs to ensure the highest level of compliance.

Duties & Responsibilities:

  • Identify trends and recommend ideas for improvement

  • Work with A&G leaders to ensure training and documentation supports successful QA results

  • Oversee processes to deliver high quality ratings in support of Centers for Medicare & Medicaid Services (CMS) and state requirements

  • Support review of audit requests, regulatory reporting requests, and universe submission requests

  • Ensure QA results are leveraged appropriately to improve and maximize A&G performance

  • Monitor group and individual performance and progress against goals

  • Maintain delegated vendor relationship and ensure vendor performance and compliance measures are met

  • Recommend best practices and strategically deploy approaches to perform A&G tasks

  • Maintain working relationships within various operational areas to identify and execute overall process improvements

  • Communicate A&G results and collaborate with operations partners

  • Build partnerships with business areas outside of operations to improve communication and responsiveness

  • Diagnose and understand operational challenges in addition to skill gaps in order to provide leadership and management to the Appeals & Grievances team

  • Drive the development of documentation, innovative tools and processes to assist in overall handling of Appeals & Grievances functions

  • Support use and updates of systems in place for delivery of quality of results

  • Additional duties as assigned

Minimum Qualifications:

  • Bachelor's degree from an accredited institution or equivalent work experience

  • Experience managing a team and leading work processes in a fast-paced environment

  • Experience preparing and delivering written and verbal information to multiple types of audiences

  • Experience in supporting quality programs, audits and/or regulatory requirements

  • Demonstrated ability to work well with others, understand process flows and correlating platforms, recommend options and implement solutions

  • Experience managing staff performance

  • Experience managing multiple concurrent priorities

Preferred Qualifications:

  • Experience in A&G and proven success in developing a comprehensive quality program with clear guidelines, expected results, and calibration.5+ years of healthcare appeals experience

  • Proven ability to work across areas in an organization to yield results

  • Experience with appeals and grievance processing and compliance

  • MBA or Master's degree from an accredited institution with focus in training & development, education, business, or healthcare administration

  • Six Sigma Black Belt or related process / operational improvement experience

  • Leadership experience in an focus area of operational excellence or audit

  • Management experience in an operational department within the healthcare industry

  • Experience developing strategy and processes for a department or function

  • Experience managing vendors as an extension of a core team. Familiar with creating accountable ownership of a vendor team

Compliance & Regulatory Responsibilities: Noted above

License/Certification: N/A

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

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