Director Grievances & Appeals

Delta Dental•San Francisco, CA

18h

About The Position

The Director of Grievance and Appeals assumes leadership for the program development and strategic planning of the Delta Dental Grievance and Appeals Department. This role guides and develops the G&A leadership team ensuring that all operations, including the processing of appeals, grievances, and regulatory complaints, meet compliance standards and adherence to multiple state and federal -mandated standards, guidelines and reporting requirements. The Director works closely with various stakeholders to identify trends in complaints and makes recommendations that will improve the patient and provider experience.

Requirements

12+ years w/Bachelor’s degree; 3+ years management
Additional experience may be accepted in lieu of education or degree
A minimum of 6 years of related G&A experience.
A minimum of 5 years of leadership experience of 150+ person organization, preferably with some union environment experience.
Core skills in project and program management, portfolio strategy/management, and organizational change management.
Proven ability to lead teams, develop people and influence others.
Excellent interpersonal skills and the ability to work effectively and build partnerships at all levels of the organization, including C-Suite.
Skill in translating complex trends, processes, outcomes and data into easily understandable and actionable concepts.
Ability to develop strategies and strategic solutions, and drive through to execution.
Proven ability to work effectively in a matrixed environment.
Strong critical thinking, problem-solving and analytical skills.
Strong organizational/time management skills with the ability to multi-task.
Knowledge of health care operations and provider network development; knowledge of Delta Dental enterprise operations preferred.
Knowledge of Current Dental Terminology (“CDT”) codes and dental nomenclature.
Knowledge of enterprise’s processing policies and guidelines for dental procedures, limitations and exclusions.
Demonstrated excellence in communication and negotiation, especially in complex settings and in a cross-cultural environment.
Knowledge of quality improvement methodologies such as Lean Six Sigma.
Ability to travel to various operations sites required.

Nice To Haves

Six Sigma Green Belt Certification.
Lean Six Sigma Black Belt.
Certified Project Management Professional (PMP)-PMI.

Responsibilities

Directs and oversees department strategy, operations and compliance with regulatory-required (e.g., CMS, DHCS, DMHC and NCQA) grievance and appeals processes, protocols, and activities.
Ensures that department processes and procedures support overall Quality Improvement program requirements and meet accreditation, audit and Company standards.
Leads collaborative efforts with enterprise departments to continuously pursue opportunities for improvement that stem from grievance data and appeals trends.
Leads cross-functionally to ensure that initiatives are executed successfully, results and outcomes are measured, and insights are shared back to all stakeholders.
Defines and implements organizational structure to facilitate business performance.
Ensures optimization of resources by resolving any duplicative improvement efforts and organization structures.
Serves as the Chair of the Grievance Insight Committee, providing direction and recommendations based on Grievance and appeals trends.
Creates an environment that promotes employee engagement and job satisfaction within the department.
Develops and manages annual department and project budgets; identifies variances and takes corrective actions as appropriate.
Develops and implements departmental policies, procedures, and work flows incorporating new processes into existing systems and work flows while ensuring compliance with federal, state, and accrediting agencies.
Represents Grievance and Appeal Department for all audits including pre-exam audit preparation, mock exams, actual audits, preparation of corrective action plans, and follow-up with regulators.