Manager, Member Resolution - Grievance & Appeals

The Manager, Member Resolution will lead a high-impact team within the Grievance & Appeals (G&A) department, overseeing the resolution of pre-service and post-service member appeals, member-submitted grievances, and appeal requests submitted by out-of-network providers. This role ensures compliance with all applicable regulatory, accreditation, and contractual requirements while advancing member-centric outcomes and operational efficiency. This leader will be responsible for the daily operations of a team of up to 15 employees, including two direct Supervisor reports. The successful candidate will be a transformational leader, capable of driving the transition from manual case processing to a more automated, data-informed workflow environment. A strong background in Medicare, regulatory compliance, reporting/analytics, and workflow redesign is strongly preferred.

We're looking for leader with:

• Experience: 7 years' relevant experience to include leadership experience
• Education: Bachelor's Degree or equivalent work experience (Two years' relevant work experience is equivalent to one-year college)

Preferred Qualifications:

• Leadership experience in Grievance & Appeals, Case Management, Healthcare Operations, or Regulatory Operations.
• Proven experience with Medicare Advantage requirements and CMS audit preparation.
• Knowledge of state and federal regulations impacting grievances and appeals (e.g., NCQA, NAIC, CMS).
• Strong analytical and reporting skills; experience with platforms such as Salesforce, Facets, JIVA, and SharePoint is preferred.
• Demonstrated success leading teams through change, particularly in transitioning from manual to automated workflows.
• Excellent interpersonal, communication, and cross-functional collaboration skills.

What a day of a Manager Grievance & Appeals would look like:

• Lead daily operations for the Member Resolution team, ensuring timely and compliant resolution of member appeals, grievances, and out-of-network provider submissions.
• Supervise and coach direct reports, including two team Supervisors, with a focus on performance accountability, staff development, and quality improvement.
• Partner cross-functionally with Clinical, Legal, Compliance, Member Services, and IT to resolve escalations and implement systemic process improvements.
• Monitor and report on departmental metrics, case trends, and compliance indicators; use data to drive decision-making and inform executive reporting.
• Advance automation and digital transformation initiatives aimed at reducing manual processing and increasing workflow efficiency.
• Represent the department in audits, interdepartmental forums, and Medicare/Medicaid regulatory engagements as needed.
• Support enterprise goals related to STAR ratings, member satisfaction, and grievance/appeal turnaround times.

As of the date of this posting, a good faith estimate of the current pay range is $94,066 to $141,100. The position is eligible for an annual incentive bonus (variable depending on company and employee performance.

The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, shift, travel requirements, internal equity, geography, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer.

We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical/dental/vision/pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program.

We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.

Reasonable accommodations

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.