Director, Complaints, Grievances & Appeals Strategy

Sun Life; Milwaukee (WI); Hybrid; USD 115,000 - 172,000; Full time

Benefits offered by this job

Generous vacation and sick time

Paid family, parental and adoption-lea

Medical coverage

Life and AD&D insurance

Disability programs

401(k) employer match

Job summary

Sun Life U.S. is seeking a Director of Complaints, Grievances & Appeals (CG&A) to lead operations, training, and reporting. You will drive client audits, action plans, and process improvements while guiding staff performance in a data-driven model to control costs and improve outcomes.

The role requires extensive healthcare regulatory knowledge, strong leadership, and the ability to implement strategic initiatives across the department, with a hybrid in‑office schedule and travel as needed.

Qualifications

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

Responsibilities

• Establish strategic direction of the CG&A function to improve engagement, satisfaction and efficiency.
• Monitor daily and monthly turnaround time to meet client contract requirements.
• Complete and interpret monthly reports; develop action plans to address gaps.
• Ensure department meets client expectations and regulatory guidelines.
• Develop and update department policies to stay compliant with CMS/NCQA/state regs.
• Develop and implement root cause resolutions for operational issues.
• Oversee development of training materials and staff training.
• Identify and report efficiencies in department workflow.
• Participate in client audits on site or off site as needed.
• Manage Corrective Action Plans (CAP) and perform root cause analysis.
• Participate in business implementations; act as SME for CGA.
• Build an annual budget based on data; enhance operational efficiency.
• Performance manage CGA staff and adhere to processes.

Job description

Sun Life U.S. is seeking a Director of Complaints, Grievances & Appeals (CG&A) to lead operations, training, and reporting. You will drive client audits, action plans, and process improvements while guiding staff performance in a data-driven model to control costs and improve outcomes.

The role requires extensive healthcare regulatory knowledge, strong leadership, and the ability to implement strategic initiatives across the department, with a hybrid in‑office schedule and travel as needed.