Director of Complaints & Appeals Strategy

Sun Life; Wellesley (MA); Hybrid; USD 115,000 - 172,000; Full time

Benefits offered by this job

Vacation time

Family leave

401(k) match

Stock purchase plan

Flexible work environment

Job summary

Sun Life U.S. is seeking a Director of Complaints, Grievances & Appeals to lead CG&A operations, training, and reporting, ensuring client contract outcomes and data-driven cost management.

Hybrid work with in-office presence required; travel may be necessary. The role drives process improvements, CAPs, audits, and performance management of staff while aligning with CMS, NCQA, and state regulations.

Qualifications

• 7+ years' experience in healthcare or related field
• 7+ years' leadership experience
• Bachelor degree or related experience required
• Ability to travel
• Knowledge of CMS and NCQA regulations and product-type differences
• Excellent verbal and written communication with attention to detail
• Strong analytical and presentation skills
• Experience presenting to high-level management/external constituents
• Proficiency with Excel, Word, Outlook

Responsibilities

• Establish strategic direction for CG&A to improve engagement, satisfaction, and efficiency
• Monitor daily and monthly turnaround times to meet client contracts
• Produce and interpret monthly reports and develop action plans for gaps
• Ensure compliance with contracts, state laws/regulations, CMS and NCQA guidelines
• Develop and update CG&A policies and procedures for compliance
• Create root-cause resolutions for operational issues and training needs
• Oversee training materials and department guidelines implementation
• Identify and report efficiency gains in CG&A workflows
• Participate in client audits on-site or off-site as needed
• Manage Corrective Action Plans and root-cause analyses
• Participate in business implementations as SME for CGA
• Build a data-driven annual budget to improve operational efficiency
• Provide performance management for CGA staff
• Adhere to standardized business processes
• Support other duties as needed

Skills

Leadership

CMS knowledge

NCQA knowledge

Communication

Analytical skills

Presentation skills

MS Office

Education

Bachelor's degree or related field

Tools

Excel

MS Word

Outlook

Job description

Sun Life U.S. is seeking a Director of Complaints, Grievances & Appeals to lead CG&A operations, training, and reporting, ensuring client contract outcomes and data-driven cost management.

Hybrid work with in-office presence required; travel may be necessary. The role drives process improvements, CAPs, audits, and performance management of staff while aligning with CMS, NCQA, and state regulations.