Director, Complaints & Appeals — Hybrid Leadership

Sun Life; Baltimore (MD); Hybrid; USD 115,000 - 172,000; Full time

Benefits offered by this job

Generous vacation and sick time

Family, parental and adoption leave

Medical coverage

Life and AD&D insurance

Disability programs

401(k) match and stock options

Job summary

Sun Life U.S. seeks a Director, Complaints, Grievances & Appeals to lead CG&A operations, training, and reporting. You will drive client audits, implementations, CAPs and cost models while guiding a team to meet contractual turnaround times.

You will establish data-driven processes, ensure CMS/NCQA compliance, and manage budgets. Collaboration with stakeholders across departments will enable continued improvements in customer outcomes and operational efficiency.

Qualifications

• 7+ years' experience in healthcare or related field.
• 7+ years of leadership experience.
• Bachelor degree or related experience required.
• Willingness to travel as needed.
• Knowledge of CMS/NCQA and state regulations by product type.
• Excellent verbal and written communication and attention to detail.
• Strong analytical and presentation skills; able to engage senior stakeholders.
• Proficiency with Excel, Word, and Outlook implied.

Responsibilities

• Set strategic direction for CG&A to improve engagement, satisfaction, and efficiency.
• Monitor turnaround times per contract requirements and report gaps.
• Lead monthly reporting and action plans to address deficiencies.
• Ensure compliance with State laws, CMS, and NCQA guidelines.
• Develop, update policies and processes for CG&A compliance.
• Lead root-cause analysis and implement corrective actions.
• Oversee training materials and staff training on guidelines.
• Manage department budget and advocate for resources.
• Support client audits and participate in rollouts and CAPs.

Skills

Healthcare leadership

CMS/NCQA knowledge

Data analysis

Verbal communication

Written communication

MS Office (Excel, Word, Outlook)

Presentation skills

Travel willingness

Budgeting

Education

Bachelor's degree

Tools

Excel

MS Word

Outlook

Job description

Sun Life U.S. seeks a Director, Complaints, Grievances & Appeals to lead CG&A operations, training, and reporting. You will drive client audits, implementations, CAPs and cost models while guiding a team to meet contractual turnaround times.

You will establish data-driven processes, ensure CMS/NCQA compliance, and manage budgets. Collaboration with stakeholders across departments will enable continued improvements in customer outcomes and operational efficiency.