Director, Complaints & Appeals — CG&A Leader

Sun Life; Hartford (CT); Hybride; USD 115 000 - 172 000; Plein temps

Avantages offerts par ce poste

Vacation and sick time

401(k) employer match

Stock purchase options

Flexible, inclusive work environment

Résumé du poste

Sun Life U.S. is hiring a Director of Complaints, Grievances & Appeals (CG&A) to lead and optimize CG&A operations, training, and reporting. You will participate in client audits, implement process improvements, and guide staff performance evaluations.

The role focuses on a data-driven operating model to control costs and improve service levels. You will ensure compliance with CMS, NCQA, and state regulations, develop CAPs, budgets, and strategic initiatives.

Qualifications

• 7+ years' experience managing in healthcare or related field.
• 7+ years of leadership experience.
• Bachelor degree or related experience.
• Ability to travel.
• Knowledge of CMS and NCQA requirements and state regulations.
• Excellent verbal and written communication and analytical skills.
• Experience presenting to high-level management/external constituents.
• Proficient with common office software (Excel, Word, Outlook).

Responsabilités

• Set strategic direction for CG&A function to improve engagement, satisfaction, and efficiency.
• Monitor turnaround times to meet client contract requirements.
• Produce and interpret monthly reports; implement corrective action plans.
• Ensure compliance with state laws, CMS, and NCQA guidelines.
• Develop and update CG&A policies and processes.
• Lead training materials and department trainings.
• Identify workflow efficiencies and quantify benefits.
• Lead client audits on/off site as needed.
• Manage CAPs and root-cause analyses.
• Support business implementations and act as SME for CG&A.
• Develop annual data-based budget; drive operational efficiency.
• Manage performance of CG&A staff.
• Adhere to business processes.

Connaissances

Leadership

Healthcare domain knowledge

Analytical skills

Communication skills

Presentation skills

MS Excel

Formation

Bachelor degree in related field

Outils

CMS knowledge

NCQA knowledge

MS Word

Outlook

Description du poste

Sun Life U.S. is hiring a Director of Complaints, Grievances & Appeals (CG&A) to lead and optimize CG&A operations, training, and reporting. You will participate in client audits, implement process improvements, and guide staff performance evaluations.

The role focuses on a data-driven operating model to control costs and improve service levels. You will ensure compliance with CMS, NCQA, and state regulations, develop CAPs, budgets, and strategic initiatives.