Director, Complaints Grievance & Appeals

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. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.

At Sun Life, we're driven by our Purpose: helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful.

When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives.

Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.

Job Description

Location: Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work. Our team members and leaders are expected to foster connection and teamwork by being present in the office at least 2 days per week.

The opportunity

The Director, Complaints, Grievances & Appeals (CG&A) is responsible for directing CG&A operations as well as the training and reporting functions for CG&A. This role is required to participate in client audits, presentations, implementations, corrective action plans, develop and implement process improvements, as well as meet client requirements in regards to contractual turnaround times. The Director is responsible for guiding and motivating team members and completing performance and wage evaluations of staff. This individual will also be required to establish a data driven operating model that will determine the ongoing costs of the CG&A function and the associated strategy and tactics to develop a more efficient and effective operating model.

How you will contribute

• Establish the strategic direction of the CG&A function including tactics to improve employee engagement, customer satisfaction and operational efficiency.
• Monitor daily and monthly turnaround time to ensure compliance with client contract requirements
• Complete, communicate, and interpret monthly reporting requirements and if necessary proactively develop action plans to address any gaps or potential deficiencies
• Ensure department is meeting client expectations and terms of contract requirements, State Laws/Regulations, CMS and NCQA guidelines
• Develop, create, and update department policies, procedures and processes to ensure compliance with State Laws/Regulations, CMS and NCQA guidelines
• Develop and implement root cause resolutions to internal and external operational and personnel issues
• Oversee and direct the development of training materials and training of departmental on guidelines and processes
• Identify, develop, implement, quantify and report on efficiencies in the workflow of the department.
• Participate in and complete client audits both on site and off site if needed
• Develop, implement and maintain a strategic and consistent process for Corrective Action Plans (CAP) and perform root cause analysis
• Participate in business implementation projects. Act as the Subject Matter Expert (SME) for CGA
• Build an annual budget that is data based and identify and establish processes that will enhance the efficiency of the operation.
• Performance management of CGA staff.
• Adhere to business processes
• Other duties as needed or required.

What you will bring with you

Required

• 7+ years' experience of managing in healthcare or related experience required
• 7+ years of previous leadership required
• Bachelor degree in related field or related experience required
• Ability to travel
• Requires knowledge of Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) and State Medicaid/Commercial regulations or compliance requirements and differences amongst the requirements based on Product type
• Excellent verbal and written communication skills required with attention to detail
• Excellent analytical skills required.
• Previous experience presenting to high-level management and/or external constituents required
• Excellent presentation and interpersonal skills required
• Extensive knowledge of general computer software required. (Excel, MS Word, and Outlook)

Preferred

• Knowledge of clinical and industry terminology and procedures preferred.

PHYSICAL DEMANDS

• Ability to work in a fast-paced environment with multiple interruptions
• Ability to communicate in an active office environment.
• Ability to efficiently operate all job-related office equipment.
• Ability to communicate via telephone.
• Ability to sit for 80% or more of an 8-hour workday.
• Ability to read and view computer screen.
• The area is located in a wheelchair accessible building.
• The office environment is active with high voice levels and interruptions that may challenge hearing and concentration.
• Ability to travel

Salary: $114,600 - 171,900

At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions.

We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate. We encourage applications from qualified individuals from all backgrounds.

Life is brighter when you work at Sun Life

• generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program.
• Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account.
• Enjoy a flexible, inclusive and collaborative work environment that supports career growth.
• We're proud to be recognized in our communities as a top employer.
• Proudly Great Place to Work Certified in Canada and the U.S., we've also been recognized as a 'Top 10' employer by the Boston Globe's 'Top Places to Work' for two years in a row.
• Visit our website to learn more about our benefits and recognition within our communities.

We will make reasonable accommodation to the known physical or mental limitation of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email [e-mail] to request an accommodation.

For applicants residing in California, please read our employee California Privacy Policy and Notice.

We do not require or administer lie detector tests as a condition of employment or continued employment.

Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran

Job Category

Customer Service / Operations

Posting End Date

15/11/2026