Director, Complaints Grievance & Appeals
Core
Directing complaints, grievances, and appeals (CG&A) operations for dental and vision benefits, ensuring compliance with CMS, NCQA, and state regulations while managing team performance and operational efficiency.
Role type
Senior leadership operations director (healthcare compliance)
Builds
Data-driven operating models, corrective action plans, and efficient CG&A workflows for Medicaid, CHIP, Medicare Advantage, and commercial clients.
Domain
Healthcare insurance (dental/vision) + Regulatory compliance
Deliverable
dashboards & analysis
Required skills
Healthcare operations management, CMS/NCQA/state regulation compliance, root cause analysis, strategic planning, budgeting, team performance management, data analysis, contract turnaround time management, policy development, stakeholder presentation
Preferred skills
Clinical and industry terminology knowledge
Technologies
Excel, MS Word, Outlook
Responsibilities
Establish strategic direction for CG&A function; monitor daily/monthly turnaround times; complete and interpret monthly reporting; develop policies/procedures for regulatory compliance; implement corrective action plans and root cause analysis; oversee staff training; participate in client audits; build annual budgets; manage staff performance evaluations.
Seniority
Director, strategic leadership & team management