Director, Complaints Grievance & Appeals

Sun Life Financial; Northern (KY); Hybrid; USD 115,000 - 172,000; Full time

Job summary

Sun Life Financial is seeking a Director of Complaints, Grievances & Appeals to lead CG&A operations, training, and reporting. The role requires guiding staff, managing audits, and developing efficient processes to meet client contractual timescales.

The position demands 7+ years in healthcare leadership, CMS/NCQA knowledge, and strong communication. Hybrid work is offered, with travel as needed and a data-driven approach to budgeting and performance management.

Qualifications

• 7+ years of managing in healthcare or related experience.
• 7+ years of leadership experience.
• Bachelor degree in related field or related experience.
• Ability to travel.
• Knowledge of CMS and NCQA regulatory requirements.
• Excellent verbal and written communication skills.
• Experience presenting to senior management.
• Proficiency with MS Office applications.

Responsibilities

• Establish strategic direction for CG&A with focus on engagement, satisfaction and efficiency.
• Monitor turnaround times to ensure contract compliance.
• Lead audits, reporting, and corrective action plans.
• Develop and update department policies and training materials.
• Build a data-driven operating model and budget.
• Provide performance management and coaching to CG&A staff.
• Ensure compliance with CMS/NCQA and State regulations.

Skills

Leadership

Healthcare experience

CMS/NCQA knowledge

Communication

Analytical skills

Presentation skills

Travel ability

Stakeholder management

Education

Bachelor's degree

Tools

Excel

MS Word

Outlook

Job description

**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