VP, Provider and Member Appeals & Grievances
Core
Enterprise leader accountable for the full strategic, operational, regulatory, and people management functions of non-contracted provider and member appeals, grievances, and CTM programs, ensuring timely, accurate, and compliant adjudication in accordance with CMS regulations.
Role type
VP of Provider and Member Appeals & Grievances
Builds
A high-performing, multi-layered leadership organization driving Caring Connections, managing compliance risk, and delivering measurable improvement across quality, timeliness, and member/provider outcomes.
Domain
Health Insurance / Medicare Advantage / Regulatory Compliance
Deliverable
client delivery
Required skills
Strategic roadmap development, governance structure establishment, budget management, organizational design, executive-level presentation, regulatory audit leadership, cross-functional collaboration, team leadership, data-driven decision making, change management, vendor management.
Preferred skills
Board or executive level presentation experience, Master's degree (MHA, MBA, MPH).
Technologies
CMS Parts C & D, NCQA standards, DTS, Data teams.
Responsibilities
Develop and maintain the strategic roadmap for the member and non-contracted provider appeals program; Establish governance structure, oversight routines, and operational policies to ensure compliance; Own and manage the appeals and grievances operating budget planning; Lead organizational design and workforce structure for the full function; Serve as the primary organizational voice to CMS, external regulatory bodies, and accreditation agencies; Oversee day-to-day operations and staff management of appeals and grievance intake, routing, clinical reviews, and final determination issuance; Ensure appeals and grievances are resolved within all CMS-mandated timeframes and internal SLAs; Lead and develop a multi-level leadership team including Directors, Senior Managers, and Managers responsible for the day-to-day operations of both functions.
Seniority
VP, enterprise-level strategy & mentorship