Grievance and Appeals Regulatory Oversight Manager (45238)

The Grievance and Appeals Regulatory Oversight Manager works collaboratively with the Senior Manager of Grievance and Appeals and the Director of Quality Management and Grievance and Appeals to provide strategic and operational oversight of all regulatory requirements, compliance and reporting obligations related to Medicare, Medicaid, Exchange and other applicable lines of business for grievance and appeals.

The Grievance and Appeals Regulatory Oversight Manager ensures adherence to federal, state, accreditation, and contractual requirements through effective monitoring, auditing, reporting, and policy management. This position evaluates operational performance, identifies compliance risks and improvement opportunities, and develops corrective actions to promote regulatory readiness and operational excellence. In addition, serves as a regulatory subject matter expert for grievance and appeals, supports audits and regulatory reviews including delegated functions, oversees reporting and documentation processes, and assists in the implementation of regulatory changes that enhance quality, efficiency, compliance, and member experience. The position is accountable for monitoring regulatory changes, interpreting emerging requirements, developing operational guidance, and ensuring business processes for grievance and appeals remain compliant with evolving state and federal regulations.

Duties and Responsibilities:

Responsibilities include, but are not limited to the following:

Regulatory Compliance and Oversight

• Lead and support regulatory oversight activities related to grievance and appeals.
• Monitors and ensures compliance with CMS, EOHHS, NCQA, state regulatory agencies, and contractual requirements.
• Develops, implements, and maintains policies, procedures, monitoring activities, and internal controls to ensure ongoing compliance.
• Interprets evolving regulatory requirements and communicates operational impacts and recommendations to leadership.
• Supports implementation of regulatory changes and ensure timely operational readiness.
• Lead internal monitoring, auditing, and compliance validation activities.
• Coordinate and support internal and external audits, regulatory reviews, accreditation surveys, and government examinations.
• Develop, implement, and monitor corrective action plans through successful resolution.

• Evaluate operational processes and outcomes to identify opportunities for process improvement, increased efficiency, and risk reduction.
• Analyze grievance, appeal, overturn, timeliness, and complaint trends to identify root causes and recommend corrective actions.

• Oversee regulatory reporting requirements and ensure accuracy, completeness, and timely submission of required reports.
• Develop reporting methodologies, dashboards, and performance metrics to monitor operational and regulatory performance.
• Utilize data analytics to identify trends, operational risks, quality concerns, and compliance opportunities.
• Present findings and recommendations to leadership.

• Lead the development, review, implementation, and maintenance of departmental policies, procedures, desktop procedures, and regulatory guidance documents.
• Ensure policies are operationally effective, compliant with applicable regulations, and aligned with organizational strategies.
• Collaborate with business partners to maintain accurate and current regulatory and operational documentation.

• Participate in cross-functional projects designed to improve member experience, compliance outcomes, and operational effectiveness.

• Support departmental projects, strategic initiatives, and regulatory implementations.
• Serve as a regulatory resource and subject matter expert for internal business partners.

• Maintain compliance with the organization's Corporate Compliance Program, Standards of Business Conduct, applicable laws and regulations, and departmental policies and procedures.
• Exercise due diligence in identifying, preventing, and reporting compliance risks, unethical conduct, fraud, waste, abuse, and other regulatory concerns.

Vendor and FDR Oversight

• Serve as the business lead for assigned First Tier, Downstream, and Related Entities (FDRs).
• Develop and maintain a comprehensive oversight program for Grievance and Appeal delegated activities.
• Conduct ongoing monitoring of delegated functions, including:
  
  
  
  • Appeals and grievances
  • First Call Resolutions
  • Timely grievance referrals
  • Member and provider communications
  • Website and portal content
  • Letter template compliance
  • Regulatory submissions and reporting
  
  
  
  
• Conduct operational reviews, performance evaluations, and compliance assessments of delegated entities.
• Ensure vendors maintain compliance with applicable regulations, contractual obligations, and organizational standards.
• Perform other duties and special projects as assigned.

Qualifications

Required:

• Bachelor's degree in Healthcare Administration, Public Health, Nursing or related field.
• 5+ years of experience in healthcare regulatory compliance or grievance and appeals, or managed care operations.
• Demonstrated experience with Medicare, Medicaid/EOHHS, and NCQA regulatory requirements.
• Demonstrated expertise in interpreting and operationalizing contractual and regulatory requirements, including the identification and mitigation of associated risks.
• Experience supporting regulatory compliance and audits, and oversight experience with CMS, EOHHS, NCQA, and other regulatory agencies.
• Experience managing vendor/FDR oversight programs and corrective action plans.
• Strong analytical and problem-solving skills with the ability to identify trends and implement corrective actions.
• Strong written and verbal communication skills, including presentation and facilitation abilities.
• Ability to manage multiple priorities and work independently in a fast-paced, highly regulated environment.
• Proficient in Microsoft Office Suite, including Excel, Word, Outlook, and PowerPoint.

Preferred:

• Masters degree
• Experience with Medicare Advantage, Medicaid, Exchange, and Dual Eligible Special Needs Plans (DSNPs) programs.
• Experience with CMS program audits and reporting requirements.
• Experience developing and maintaining operational, clinical, and administrative policies and procedures.
• Clinical background or RN licensure

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.