Appeals and Compliance Specialist
Golden Gate Regional Center
- San Francisco, CA
- $84,495-101,395 per year
- Permanent
- Full-time
- Lead and oversee the appeal process from submission to resolution, including informal meetings, negotiation settlement of mediations, Early Start and Lanterman Appeals and other complaints outlined on DDS’ website under
- Represent GGRC at mediation sessions and appeal hearings, ensuring effective communication and resolution.
- Prepares staff to act as witnesses for appeal hearings.
- Serves as the custodian of records for all matters related to those served and monitors/responds to HIPPA violations for Regional Center Services and Community Services.
- Adhere to legal timelines during the appeal process and participate in conference calls with Administrative Law Judges and claimants.
- Compile monthly status reports and an annual report on appeals, offering insights and recommendations.
- Analyze appeals and hearings, prepare statistical reports to identify trends and optimize agency overall effectiveness.
- Collaborate with internal departments to streamline the appeals process and improve efficiency.
- Conduct regular audits of appeal documentation and procedures to ensure accuracy and compliance.
- Provides consultation and training to staff on the requirements of the Lanterman Act, Title 17, and GGRC’s purchase of services guidelines, ensuring compliance and understanding.
- Provides consultation and training to staff on Notices of Action and the appeal process for both those served and vendors.
- Investigates and responds to W & I 4731 and whistleblower complaints within mandated timelines, maintaining accountability and transparency.
- Oversees tracking of 4731 complaints and ensures timely reporting to DDS.
- Serve in a consultation capacity for social workers and their managers on all matters related to the denial of services including reductions in services.
- Collaborate with legal counsel as needed and ensure GGRC compliance with regulations and statutes.
- Ensures accuracy of legal forms i.e. Release of Information.
- Support case management staff to help protect the rights and legal interest of those served within the requirements of what a regional center can legally provide in the form of support and services.
- Review, advise, and ensure GGRC compliance with the regulations and statutes including all 4731 complaints and whistleblower complaints as designated by the Executive Director.
- Monitor the timely submission of regional center-specific reports required by DDS.
- Develop and maintain Memorandums of Understanding between the regional center and our community partners (i.e., foster care, mental health, school districts, healthcare plans, Disability Rights California Office of Client’s Rights, etc.).
- Establish, maintain, and promote positive interpersonal relationships with staff and members of the community, including those served, families, and staff in the community, service providers and government offices.
- Stay informed about public transparency regulations, industry best practices, internal standards, and organizational goals, providing relevant training to address common appeals issues and incorporating new knowledge into GGRC’s practices.
- Any other relevant duties as assigned by the supervisor.
- Bachelor’s degree in social work, psychology, public or business administration, or related field. Master’s degree preferred.
- Minimum five years of experience working with developmental disabilities or related friends.
- Minimum three years of experience in a similar role with a social services agency, legal environment, or healthcare setting.
- Strong understanding of legal processes and regulations relevant to appeals, including knowledge of the Lantermant Act, Title 17 and HIPAA.
- Experience representing organizations at mediation sessions, and appeal hearings with a track record of effective communication and conflict resolution.
- Experience participating in administrative appeals.
- Previous work experience in a Regional Center a plus
- Ability to apply relevant laws, regulations, requirements, and policy standards.
- Negotiate successfully and prepare effective presentations for administrative law judges.
- Ability to interpret and apply a variety of legal requirements and policy standards.
- Ability to handle a wide variety of situations and complex issues.
- Ability to handle change well and be flexible and adaptable in dealing with interruptions, new priorities, and new assignments.
- Multi-task, work well under pressure, prioritize, and produce within deadlines.
- Ability to prepare statistical and narrative reports.
- Ability to establish and maintain effective communications and operational network.
- Ability to convey complex information and ideas to diverse groups clearly, concisely, both verbally and in writing.
- Strong organizational skills with the ability to prioritize tasks, meet deadlines, and maintain accuracy and compliance in appeal documentation and procedures.
- Excellent interpersonal skills with the ability to establish and maintain positive relationships with those served, families, staff, and community partners.
- Ability to operate basic office equipment and use software applications like MS Word, Excel, PowerPoint, and Outlook.
- Ability to operate basic office equipment, including scanners, copiers, faxes, phones.
- Self-motivated and takes initiative.
- Understands and effectively reacts/adapts to multiple and competing priorities on the job; uses knowledge and expertise to focus on key job outcomes.
- Legal Compliance
- Negotiation Skills
- Communication Proficiency
- Adaptability
- Organizational Skills
- Interpersonal Skills
- Problem solving Ability
- Teamwork and Collaboration
- Initiative and Self-Motivation
- Attention to Detail
- Ethical Conduct
- Customer Service Orientation
- Experience in the Regional Center System
- Experience in multi-cultural settings and/or multi-lingual capacity