Director, Appeals and Grievances, Health Plan

Sanford Health•Sioux Falls, SD

About The Position

Sanford Health is one of the largest and fastest-growing not-for-profit health systems in the United States. We’re proud to offer many development and advancement opportunities to our nearly 50,000 members of the Sanford Family who are dedicated to the work of health and healing across our broad footprint. Work Shift: 8 Hours - Day Shifts (United States of America) Scheduled Weekly Hours: 40 Union Position: No Department Details Summary This role is responsible for the strategic oversight and operational management of the organization’s member and provider appeals, complaints, and grievance processes across all product lines, including ACA, Commercial, Medicare Advantage, Medicaid, DSNP, and ISNP. This role ensures adherence to all state, federal, CMS, HHS, and quality regulations governing appeals and grievance resolution.

Requirements

Bachelor’s degree in Health Administration, Public Policy, Business, Law, or a related field required.
Minimum of 7 years of experience in health plan appeals and grievances, regulatory oversight, or health policy.
At least 3 years in a leadership role managing appeals, grievances, or regulatory review functions.
Strong knowledge of CMS, Medicaid, ACA, and Commercial appeals and grievances regulations.

Nice To Haves

Master’s degree preferred.

Responsibilities

Lead and manage the end-to-end appeals and grievances process for all product lines, ensuring compliance with federal and state requirements.
Oversee the intake, review, resolution, and documentation of all appeals, complaints, and grievances to meet regulatory and operational standards.
Ensure all cases are resolved within required timeframes, with appropriate levels of review, documentation, and notification to members and providers.
Monitor and report appeals and grievance trends, identifying areas for improvement in operational workflows and regulatory compliance.
Oversee processes related to Independent Review Entities (IREs), Administrative Law Judge (ALJ) hearings, and external dispute resolution bodies.
Ensure strict adherence to CMS, HHS, state Medicaid agencies, and DOI regulations regarding appeals and grievances processes.
Lead audits, reporting, and corrective actions related to appeals, grievances, and regulatory inquiries.
Work closely with Quality, Policy & Regulation, and other teams to integrate regulatory changes into internal workflows.
Prepare and submit all required regulatory reports, ensuring accuracy and alignment with agency expectations.
Act as the primary liaison with state and federal regulators on matters related to appeals and grievances.
Represent the organization in regulatory meetings, audits, and compliance reviews related to appeals and grievances processing.
Collaborate with legal, compliance, operations, and medical management teams to address complex cases and ensure proper resolution.
Develop and implement strategies to improve member satisfaction and provider engagement related to dispute resolution.
Identify and implement best practices and technology solutions to improve efficiency in appeals and grievances resolution.
Oversee training and professional development programs for appeals and grievances staff to maintain expertise and regulatory knowledge.
Drive continuous improvement initiatives to enhance timeliness, accuracy, and quality of appeal determinations.
Partner with Quality and Operations teams to evaluate trends, root causes, and corrective action plans to improve service delivery.