Director, Appeals & Grievances (Remote)

Sentara Health; Virginia Beach (VA); On-site; USD 140,000 - 180,000; Full time

Benefits offered by this job

Medical, Dental, Vision plans

Adoption, Fertility and Surrogacy Reim

Paid Time Off and Sick Leave

Paid Parental & Family Caregiver Leave

Emergency Backup Care

Life Insurance

401k/403B with Employer Match

Tuition Assistance – $5,250/year and $

Student Debt Pay Down – $10,000

Pet Insurance

Legal Resources Plan

Annual discretionary bonus

Job summary

Sentara Health is seeking a Director of Appeals and Grievance to plan, develop, and direct department services for existing and new business opportunities. You will set strategic long-term goals for Commercial, Medicaid, and Medicare, partnering with Medical Directors to refine criteria and benefits.

You will oversee complaints and grievances reporting, ensure compliance with contracts and regulations, and manage audits (NCQA, EQRO, CMS, DMAS, BOI). Remote.US remote work supported.

Qualifications

• Bachelor's Degree (Required).
• Minimum five years of experience with Healthcare Complaints/Appeals.

Responsibilities

• Plan, develop, and direct the Appeals and Grievance department services and activities for existing and new business opportunities.
• Set strategic long-term goals for Commercial, Medicaid, and Medicare business.
• Provide oversight for complaints, appeals and grievances reporting and analysis, interfacing with Member Services on KPIs.
• Oversee staff to resolve needs for ad hoc requests and ongoing projects related to appeals and grievances.
• Work with Medical Directors to identify trends and adjust Medical Criteria and Benefit covered items.
• Ensure compliance with contracts, SHP policies, and Federal/State/Accreditation regulations.
• Oversee external audits (NCQA, EQRO, CMS, DMAS, BOI) and meet department SLAs.
• Manage work inventories and relationships with other departments; drive department outcomes.
• Support Compliance and Internal Audit with corrective action plans to avoid recurrence.
• Contribute to Sentara Health Plans’ success.

Education

Bachelor's Degree (Required)

Job description

Sentara Health is seeking a Director of Appeals and Grievance to plan, develop, and direct department services for existing and new business opportunities. You will set strategic long-term goals for Commercial, Medicaid, and Medicare, partnering with Medical Directors to refine criteria and benefits.

You will oversee complaints and grievances reporting, ensure compliance with contracts and regulations, and manage audits (NCQA, EQRO, CMS, DMAS, BOI). Remote.US remote work supported.