Director, Complaints Grievance & Appeals

Sun Life•Milwaukee, CT

23h•Hybrid

About The Position

Sun Life U.S. is seeking a Director, Complaints, Grievances & Appeals (CG&A) to direct CG&A operations, training, and reporting functions. This role involves participating in client audits, presentations, implementations, and developing corrective action plans. The Director will also focus on process improvements, meeting client requirements for contractual turnaround times, guiding and motivating team members, and conducting performance evaluations. A key responsibility is establishing a data-driven operating model to manage ongoing costs and develop a more efficient and effective operational strategy. Sun Life embraces a hybrid work model, requiring team members to be in the office at least 2 days per week.

Requirements

7+ years’ experience of managing in healthcare or related experience required
7+ years of previous leadership required
Bachelor degree in related field or related experience required
Ability to travel
Requires knowledge of Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) and State Medicaid/Commercial regulations or compliance requirements and differences amongst the requirements based on Product type
Excellent verbal and written communication skills required with attention to detail
Excellent analytical skills required.
Previous experience presenting to high-level management and/or external constituents required
Excellent presentation and interpersonal skills required
Extensive knowledge of general computer software required. (Excel, MS Word, and Outlook)

Nice To Haves

Knowledge of clinical and industry terminology and procedures preferred.

Responsibilities

Establish the strategic direction of the CG&A function including tactics to improve employee engagement, customer satisfaction and operational efficiency.
Monitor daily and monthly turnaround time to ensure compliance with client contract requirements.
Complete, communicate, and interpret monthly reporting requirements and proactively develop action plans to address any gaps or potential deficiencies.
Ensure department is meeting client expectations and terms of contract requirements, State Laws/Regulations, CMS and NCQA guidelines.
Develop, create, and update department policies, procedures and processes to ensure compliance with State Laws/Regulations, CMS and NCQA guidelines.
Develop and implement root cause resolutions to internal and external operational and personnel issues.
Oversee and direct the development of training materials and training of departmental on guidelines and processes.
Identify, develop, implement, quantify and report on efficiencies in the workflow of the department.
Participate in and complete client audits both on site and off site if needed.
Develop, implement and maintain a strategic and consistent process for Corrective Action Plans (CAP) and perform root cause analysis.
Participate in business implementation projects.
Act as the Subject Matter Expert (SME) for CGA.
Build an annual budget that is data based and identify and establish processes that will enhance the efficiency of the operation.
Performance management of CGA staff.
Adhere to business processes.
Other duties as needed or required.