Director, Grievances & Appeals – Managed Care

Blue Cross & Blue Shield of Rhode Island; Providence (RI); Hybrid; USD 102,000 - 164,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

Tuition reimbursement

Student loan repayment assistance

Flexible work arrangements

Bonuses and investment plans

Paid time off

Job summary

Blue Cross & Blue Shield of Rhode Island in Providence is seeking a senior leader to direct the development and administration of the unit responsible for resolving member and provider grievances and appeals. You will oversee coordination of complaints across products and ensure compliance with state, federal, and CMS requirements.

The role emphasizes leadership of first-line management, program implementation, performance measures, and timely regulatory reporting.

Qualifications

• Bachelor’s degree in Business Management, Business Administration, or Healthcare Administration.
• 7–10 years experience in managed care or health plan operations.
• 5–7 years management experience leading a team.
• Knowledge of Medicare/Medicare Managed Care and Part D programs.
• Knowledge of grievance and appeals processes and health insurance laws.

Responsibilities

• Oversee the work of the unit responsible for the resolution of member and provider grievances and appeals.
• Provide leadership and direction to first line management including performance management oversight and employee development.
• Direct the implementation and administration of the company’s member and provider grievance and appeals programs.
• Oversee the coordination, research, negotiation, and resolution of member and provider complaints, grievances and appeals for all products.
• Ensure timely and accurate achievement of performance measures.
• Ensure the timely submission of regulatory reporting.
• Oversee the completion of program metrics, monitoring improvement and compliance.
• Develop and implement quality improvement strategies based on the identification of the origin of complaints and appeals.
• Monitor and measure process improvement.
• Ensure policies and procedures are current with all state and federal regulations and CMS requirements to ensure organizational compliance.
• Develop and ensure adherence to goals and deadlines.
• Perform other duties as assigned.

Skills

Leadership

Regulatory compliance

Budget management

Negotiation

Mentoring/coaching

Stakeholder management

Communication skills

Education

Bachelor's degree in Business Management/Administration or Healthcare Administration

Job description

Blue Cross & Blue Shield of Rhode Island in Providence is seeking a senior leader to direct the development and administration of the unit responsible for resolving member and provider grievances and appeals. You will oversee coordination of complaints across products and ensure compliance with state, federal, and CMS requirements.

The role emphasizes leadership of first-line management, program implementation, performance measures, and timely regulatory reporting.