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Manager Grievance &amp; Appeals (Provider Services) CalOptima CalOptima Health is seeking a highly motivated an experienced Manager, Grievance &amp; Appeals (Provider Services) to join our team. The Manager Grievance &amp; Appeals (Provider Services) will provide daily oversight and technical management for provider services, including provider disputes, provider grievances and provider appeal to ensure compliance with state, federal and accreditation standards applicable to CalOptima Health. The incumbent will work with CalOptima Health management staff and other affiliated health networks with a close interface to the program and process, including areas such as Utilization Management, Claims Administration, Delegation Oversight, Quality Improvement and health network relations. The incumbent will research complex claims problems, isolate root causes and partner with various entities for resolution. The incumbent will communicate with all levels of internal staff, regulatory agencies, health networks, providers, vendors, community-based organizations and medical groups. Position Information: 
<ul>
<li>Department: GA - Provider Disputes </li>
<li>Salary Grade: 315 - $109,892 - $175,827 ($52.83 - $84.5322) </li>
<li>Work Arrangement: Partial Telework **This position is eligible for telework in California.** </li>
</ul>
 Duties &amp; Responsibilities: 
<ul>
<li>50% - Program Oversight
<ul>
<li>Identifies and analyzes trends, collaborates with the Director to provide trends and makes recommendations for improvement.</li>
<li>Stays current on the local, state and federal health care environment, identifying issues that may impact CalOptima Health's programs as they relate to claims, provider disputes, grievances and provider appeals.</li>
<li>Develops, implements, maintains and reviews the adequacy of the CalOptima Health provider grievance systems, reporting, policies and functions to achieve stated goals, including, but not limited to, complaint resolution and timely responsiveness for all lines of business, to ensure compliance with all relevant regulatory requirements pertaining to provider disputes.</li>
<li>Works with the Audit and Oversight department and key departments to ensure internal departments and external partners (e.g., health networks and delegates) are up to date with regulatory, departmental and organizational changes impacting the grievance and appeals processes.</li>
<li>Ensures timely and effective data collection, summarization, integration and reporting, including, but not limited to, productivity, status and trend reports for specific committees such as the Quality Improvement Committee, Grievance and Appeals Committee, Quality Assurance Committee of the Board of Directors and other ad hoc reporting as required.</li>
<li>Serves as CalOptima Health's primary point of contact and subject matter expert related to provider services (disputes, grievances and appeals).</li>
<li>Participates in Department of Managed Healthcare (DMHC), Department of Health Care Services (DHCS) and Centers for Medicare and Medicaid (CMS) audits related to area of responsibility for all CalOptima Health programs. </li>
</ul>
</li>
<li>45% - Leadership
<ul>
<li>Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.</li>
<li>Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.</li>
<li>Manages, hires, mentors and develops department staff.</li>
<li>Oversees the development and maintenance of internal policies and procedures and desktops to ensure compliance with all state and federal regulations for multiple lines of business.</li>
<li>Manages and makes recommendations on the development and maintenance of an effective dispute, appeals and grievance process and systems consistent with CalOptima Health policies and stated goals, including, but not limited to mechanisms to monitor provider disputes, grievances and appeals involving Legal, DMHC, DHCS, Independent Medical Review, Medi-Cal State Hearings, Office of Administrative Hearings and Appeals, CMS and external review agencies for CMS.</li>
<li>Partners with the management to ensure appropriate training and auditing tools are developed and maintained for the department. </li>
</ul>
</li>
<li>5% - Other
<ul>
<li>Completes other projects and duties as assigned. </li>
</ul>
</li>
</ul>
 Minimum Qualifications: 
<ul>
<li>Bachelor's degree in business administration, nursing, healthcare administration or related field PLUS 3 years of health care management experience in a related area of responsibility (provider disputes and appeals, claims administration, appeals and grievances) 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. </li>
<li>3 years of leadership experience required. </li>
<li>Experience in health maintenance organization, Medi-Cal/Medicaid, Medicare Advantage, Medicare Part D, Special Needs Plans, Medicare-Medicaid Plans and/or the Program of All-Inclusive Care for the Elderly required.</li>
</ul>
 Preferred Qualifications: 
<ul>
<li>Experience with process improvement implementation.</li>
</ul>
 Required Licensure / Certifications: 
<ul>
<li>N/A</li>
</ul>
 Knowledge &amp; Abilities: 
<ul>
<li>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. </li>
<li>Work independently and exercise sound judgment.</li>
<li>Communicate clearly and concisely, both orally and in writing.</li>
<li>Work a flexible schedule; available to participate in evening and weekend events.</li>
<li>Organize, be analytical, problem-solve and possess project management skills.</li>
<li>Work in a fast-paced environment and in an efficient manner.</li>
<li>Manage multiple projects and identify opportunities for internal and external collaboration.</li>
<li>Motivate and lead multi-program teams and external committees/coalitions.</li>
<li>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.</li>
</ul>
 Physical Requirements (With or Without Accommodations): 
<ul>
<li>Ability to visually read information from computer screens, forms and other printed materials and information.</li>
<li>Ability to speak (enunciate) clearly in conversation and general communication.</li>
<li>Hearing ability for verbal communication/conversation/responses via telephone, telephone systems, and face-to-face interactions.</li>
<li>Manual dexterity for typing, writing, standing and reaching, flexibility, body movement for bending, crouching, walking, kneeling and prolonged sitting.</li>
<li>Lifting and moving objects, patients and/or equipment 10 to 25 pounds</li>
</ul>
 Work Environment: If located at the 500, 505 Building or a remote work location: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed.</li>
<li>There are no harmful environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate.</li>
</ul>
 If located at PACE: 
<ul>
<li>Work is typically indoors in a clinical setting serving the frail and elderly.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 If located in the Community: 
<ul>
<li>Work is typically indoors and sedentary and is subject to schedule changes and/or variable work hours, with travel as needed. </li>
<li>Employee will occasionally work outdoors in varied temperatures.</li>
<li>There may be harmful or hazardous environmental conditions present for this job.</li>
<li>The noise level in this work environment is usually moderate to loud.</li>
</ul>
 About CalOptima Health: CalOptima Health is the single largest health plan in Orange County, serving one in four residents. Our motto - "Better. Together." - is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. We are continuing to build a culture that promotes diversity and inclusion within our community where employees have a sense of belonging, and are valued for their ideas, contributions, and their unique individual perspectives they bring. CalOptima Health has been recognized as one of Orange County's best places to work, so we know there is something special about our organization. It is why people choose to work here and why they choose to stay! About our Benefits &amp; Wellness options: At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Monday or Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. For those who are interested in additional retirement savings, employees have access to 457(b) retirement plans with pre/post-tax contribution options. For more information, please click on the <a href="https://apptrkr.com/get_redirect.php?id=6357344&amp;targetURL=https://alliantbenefits.cld.bz/24caloptimacabenguide" target="_blank">2024 CalOptima Health Benefits Guide</a> and our <a href="https://apptrkr.com/get_redirect.php?id=6357344&amp;targetURL=https://alliantbenefits.cld.bz/25caloptimacabenguide" target="_blank">2025 CalOptima Health Benefits Guide</a> regarding our comprehensive benefits and wellness package. IMPORTANT APPLICATION INFORMATION AND INSTRUCTIONS Applications will be accepted on a continuous basis until a sufficient number of qualified applications have been received. The deadline for the first review of applications is July 16, 2025 at 9:00 PM (PST). Applicants are encouraged to apply early. Applicants that apply after the first review are not guaranteed to be considered for this recruitment. This recruitment may close at any time without notice after the first review date. The selection process may include, but is not limited to, a skills assessment, phone screen and interview. The successful candidate will be required to undergo a reference / background check (to include a conviction record) and if applicable also pass a post-offer pre-employment medical examination (which will include a drug screening). Internal CalOptima Health applicants should apply through InfoNet. Communication regarding your application will be sent to the email address listed on your application. Please check your email, including your SPAM folder, regularly throughout the recruitment process. You can also visit your candidate portal to receive the most up to date status of your application. CalOptima Health is committed to attracting, hiring, and retaining a diverse staff, where we will honor your unique experiences, identity, and perspectives. Our organization strives to create and maintain a workplace environment that is inclusive, equitable and welcoming so we can truly be Better Together. 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: <a href="https://apptrkr.com/6357344" target="_blank">https://jobs.caloptima.org/jobs/manager-grievance-appeals-provider-services-505-city-parkway-west-california-united-states</a> Copyright ©2025 Jobelephant.com Inc. All rights reserved. <a href="https://www.jobelephant.com/" target="_blank">Posted by the FREE value-added recruitment advertising agency</a> jeid-cf7b2c04c4b10840a8654602344b5194

Manager Grievance & Appeals (Provider Services)

National Center for Youth Law  &nbsp;
The National Center for Youth Law (NCYL) amplifies youth power,dismantles racism and other structural inequities, and builds justpolicies, practices, and culture in support of young people. Ourefforts advance justice through research, community collaboration,impact litigation, and policy advocacy that fundamentallytransforms our nation’s approach to education, health, immigration,foster care, and youth justice. Our vision is a world in whichevery young person thrives and has a full and fair opportunity toachieve the future they envision for themselves.  &nbsp;
Development Team &nbsp;
The Development Team’s mission is to ensure that NCYL has thefinancial resources needed to pursue its mission and vision, and touphold NCYL’s inclusive, youth-centered, strengths-based, andequity-focused values in all fundraising efforts and activities.NCYL’s Development Team is raising $20M+ annually from foundations,government agencies, corporations, law firms, and individuals. Weinspire NCYL supporters and educate them about NCYL’s values,impact, and work and build community and nurture strongrelationships among NCYL board members, staff, alumni, andsupporters through fundraising efforts. &nbsp;&nbsp;
Position&nbsp;
This is an excellent opportunity for someone to leverage theirfundraising experience and abilities to improve the lives ofchildren, including immigrants, LGBTQIA youth, those in the childwelfare or justice systems, children and their families who areexperiencing homelessness, and much more. This position will reportto the Senior Philanthropy Director.&nbsp;
Essential Functions&nbsp;
<ul>
<li>Oversee NCYL’sfundraising efforts, including individual donors, major donors, lawfirm giving and more.&nbsp;</li>
</ul>
<ul>
<li>Ensure that individualdonors are inspired by NCYL’s mission and vision and are activelyengaged in funding the advancement of our goals.&nbsp;</li>
</ul>
<ul>
<li>Build strongrelationships with donors and major donors and support theExecutive Director, staff, and board in doing the same. Serve asthe primary contact for donors.&nbsp;</li>
</ul>
<ul>
<li>​​​Oversee all aspectsof individual giving, including annual fundraising campaigns,research, identification, cultivation, solicitation, andstewardship of prospective and current donors.&nbsp;</li>
</ul>
<ul>
<li>Work with the SeniorDirector of Philanthropy to develop and carry out a comprehensiveand actionable Major Gifts plan.&nbsp;</li>
</ul>
<ul>
<li>​​​Manage a portfolio ofindividual major donors, moving these donors to give increasinglylarger, multi-year gift commitments.&nbsp;</li>
</ul>
<ul>
<li>Leverage board membersto engage in fundraising.&nbsp;</li>
</ul>
<ul>
<li>Collaborate with theSenior Director of Communications on strategic messaging anddigital fundraising and to raise the organization'sprofile.&nbsp;</li>
</ul>
<ul>
<li>Supervise keydevelopment staff.&nbsp;</li>
</ul>
<ul>
<li>Develop a deepunderstanding of NCYL’s programmatic work to ensure accuraterepresentation of our work to donors and the public.&nbsp;</li>
</ul>
Qualifications&nbsp;
<ul>
<li>​​​Proven track recordof raising large six figure, multi-year commitments from newsources.&nbsp;</li>
</ul>
<ul>
<li>​​​3 years’ experiencesupervising development team members.&nbsp;</li>
</ul>
<ul>
<li>Experience building amajor donor program.&nbsp;</li>
</ul>
<ul>
<li>Strong leadershipexperience with the demonstrated ability to mentor and build theskills of staff.&nbsp;</li>
</ul>
<ul>
<li>Computer proficiency andan aptitude for learning new systems and software.&nbsp;</li>
</ul>
<ul>
<li>Familiarity withSalesforce or other CRMs and grant management tools.&nbsp;</li>
</ul>
<ul>
<li>Understanding of thefunding landscape and the ability to locate opportunities for theorganization.&nbsp;</li>
</ul>
<ul>
<li>Outstandingcommunication skills, both verbal and written.&nbsp;</li>
</ul>
<ul>
<li>Able to ​​occasionallywork weekends and evenings.&nbsp;</li>
</ul>
<ul>
<li>Able to travel toattend funder meetings and participate in quarterly team retreatsand occasional meetings with leadership at headquarters.&nbsp;</li>
</ul>
PhysicalRequirements &nbsp;
Prolonged periodssitting at a desk and working on a computer. This position mayrequire some travel.&nbsp;
Salary,Benefits, and Location &nbsp;
This is afull-time, exempt position with a competitive salary of $163,379.00annually. A geographic salary differential may be applied if thecandidate resides somewhere other than the Oakland, CA, LosAngeles, CA, New York City, or Washington, DC metro areas. Thismeans that the salary would be reduced if the candidate resides inan area where the cost of labor is less than that of the SanFrancisco Bay Area.&nbsp;
NCYL provides arobust benefits package including health, dental, vision, and lifeinsurances, generous vacation and sick benefits, paid family leave,flexible spending account, employer contribution to a retirementplan, paid sabbatical, and short-term and long-term disabilityinsurance.&nbsp;
There isa strong preference for candidates to reside in the Oakland, CA,Los Angeles, CA, New York City, or Washington, DC metroareas.&nbsp;
NCYL isregistered to do business in the following 13 locations: Arizona,California, Colorado, Hawaii, Illinois, Maryland, Massachusetts,Michigan, New York, Oregon, Virginia, Washington, DC, andWisconsin. If a candidate is hired but lives in a state where NCYLis not currently registered to do business, their start date mayneed to be delayed until registration can be completed in the newstate. This process may take as much as three months tocomplete.&nbsp;
It is anticipated but not guaranteed that NCYL’s remote workapproach will be in place through 2026. If this policy is revokedprior to 2026, staff will be given at least one year's noticebefore being recalled to a NCYL office.&nbsp; &nbsp;
All positions at NCYL are at-will and paid for by grants anddonations, thus employment with NCYL will be contingent uponcontinued receipt of funding. Nothing in the statement changes theat-will employment relationship.&nbsp;
How toApply&nbsp;
Please submit acover letter and resume at the link below. Please, noemails or calls.&nbsp;
Applyat: <a href="https://recruiting.paylocity.com/Recruiting/Jobs/Details/2636691" target="_blank">https://recruiting.paylocity.com/Recruiting/Jobs/Details/2636691</a>&nbsp;
Applicantswith lived experience within any of our practice areas, and Black,Indigenous, and other people of color, are strongly encouraged toapply.&nbsp;
It is thepolicy of NCYL to provide equal employment opportunities to allApplicants (including Employees) regardless of race, ethnicity,sex, sexual orientation, gender identity or expression, pregnancy,breastfeeding, national origin, age, abilities/disabilities,neurotypicality, socioeconomic status, veteran status, maritalstatus, prior convictions, or any other protected classificationsunder federal, state, or local law.&nbsp;

Development Director, Individual Giving and Major Gifts

Manage the relationships of our high-level donors andprospects as part of a major gifts program.
The largest guide dog school in North America, Guide Dogs forthe Blind, is looking for an experienced fundraiser to join us as aSenior Philanthropic Gifts Officer. Serving as astrong advocate of our mission, you will manage a portfolio ofhigh-level donors and prospects for our major gifts program. Donorsand prospects reside mainly in California, with clusters of donorsscattered throughout the U.S. and Canada. This positionwill be based at our San Rafael, CA campus, with possible hybridwork opportunities. Travel is up to 50%.&nbsp;
What You’ll Love
<ul>
<li>We are a nonprofit, tax-exempt organization supported entirelyby private donations, so your expertise will be valued andrecognized</li>
<li>You’ll enjoy being part of our enthusiastic team of Developmentexperts as you brainstorm and discover new ways to attractdonors</li>
<li>You’ll feel personal pride in supporting our mission that meansso much to so many</li>
<li>This role offers autonomy and room for your ideas, bolstered bythe support of experts and specialists</li>
<li>You can bring your dog to work!</li>
</ul>
What You’ll Do:
<ul>
<li>Develop and manage identification, cultivation, solicitation,and stewardship strategies for individual donors and prospects</li>
<li>Qualify major donor prospects and develop specific strategiesfor each donor and prospect</li>
<li>Leverage board and other volunteer relationships and programleaders to maximize development opportunities, including designingand executing high-level solicitations</li>
<li>Practice best-in-class stewardship of donors in portfolio toincrease gift size, secure multi-year gifts, and maximizeretention</li>
<li>Utilize and update the donor database by recording activities,contacts, and strategies on an ongoing basis</li>
<li>With the help of the special events manager, create and executeintimate cultivation or donor-hosted fundraising events whennecessary</li>
<li>Track and report on overall major giving activity and results;develop and utilize tracking model; provide monthly and quarterlyincome forecasting</li>
</ul>

What You’ll Need:
<ul>
<li>10+ years of experience soliciting and successfully obtainingmajor gifts in the five- to seven-figure range</li>
<li>Strong track or performance record of attaining challengingannual fundraising goals</li>
<li>Bachelor’s degree desired</li>
<li>Working knowledge of fundraising or philanthropy guidelines,structure, and theory as well as principles of gift planning</li>
<li>Demonstrated experience using effective communication andinterpersonal skills, patience, active listening, diplomacy, andtact to build strong and engaging relationships with donors,volunteers, and all levels of staff</li>
<li>Willing and able to undertake overnight travel anywhere inNorth America up to 50% of the time</li>
<li>Current driver’s license and insurability at normal riskrates</li>
<li>Proficient in MS Office; working knowledge of SalesForce highlydesirable</li>
<li>Ability to perform basic administrative support duties andability to work proactively and function independently</li>
<li>Knowledge of and experience with people with disabilities oranimal issues is a plus</li>
</ul>

Guide Dogs for the Blind
At Guide Dogs for the Blind (GDB), we believe that everyonedeserves to move through the world safely and confidently – to livethe life they want to live. As the largest guide dog school inNorth America, we have graduated more than 16,000 guide dog teamsfrom across the U.S. and Canada since our founding in 1942. GDB notonly improves mobility for our clients, we further inclusion. Joinour team of more than 300 employees and share your passion for ourmission.
Apply
<a href="https://app.jobvite.com/j?cj=o4hfufwO&amp;s=Chronicle_of_Philanthropy" target="_blank">https://app.jobvite.com/j?cj=o4hfufwO&amp;s=Chronicle_of_Philanthropy</a>
At Guide Dogs for the Blind, we respect, value, and appreciateall differences. We welcome all qualified candidates irrespectiveof your race, color, religion, sex, gender identity or expression,sexual orientation, national origin, marital status, genetics,disability, age, or veteran status. Individuals with disabilities,especially those who are blind or visually impaired, are encouragedto apply.&nbsp; If you have a disability and need assistance and/oraccommodation with applying for a job, please feel free to contactour Human Resources department.
Pay Range
$166,000-$184,000/year

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