Hybrid Director, CG&A Operations & Compliance

sunlife; Milwaukee (WI); Hybrid; USD 130,000 - 170,000; Full time

Job summary

Sun Life U.S. seeks a Director of Complaints, Grievances & Appeals (CG&A) to lead CG&A operations, training, and reporting. You will participate in client audits, drive process improvements, and establish a data-driven operating model to control costs and enhance efficiency.

You will guide staff performance, ensure compliance with CMS/NCQA guidelines, and partner with clients to meet contractual turnaround times while fostering engagement and quality outcomes.

Qualifications

• 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 CMS and NCQA and State regulations.
• Excellent verbal and written communication skills.
• Excellent analytical skills.
• Experience presenting to high-level management.
• Excellent presentation and interpersonal skills.
• Extensive knowledge of general computer software (Excel, MS Word, Outlook).

Responsibilities

• Establish strategic direction for CG&A to improve engagement, satisfaction and efficiency.
• Monitor daily/monthly turnaround time to meet contract requirements.
• Prepare and interpret monthly reports; develop action plans for gaps.
• Ensure compliance with contract terms, state laws/regulations, CMS/NCQA guidelines.
• Develop and update CG&A policies and processes for compliance.
• Develop root cause resolutions for internal/external issues.
• Oversee training materials and department training.
• Identify and report workflow efficiencies.
• Participate in client audits on-site or off-site as needed.
• Manage Corrective Action Plans (CAP) and root cause analyses.
• Serve as SME for CGA in projects and implementations.
• Build annual budget based on data; improve operation efficiency.
• Conduct performance management of CGA staff.
• Adhere to business processes.
• Other duties as needed.

Skills

Leadership

Healthcare experience

CMS/NCQA knowledge

Data analysis

Communication skills

Budgeting

Education

Bachelor's degree

Tools

Excel

MS Word

Outlook

Job description

Sun Life U.S. seeks a Director of Complaints, Grievances & Appeals (CG&A) to lead CG&A operations, training, and reporting. You will participate in client audits, drive process improvements, and establish a data-driven operating model to control costs and enhance efficiency.

You will guide staff performance, ensure compliance with CMS/NCQA guidelines, and partner with clients to meet contractual turnaround times while fostering engagement and quality outcomes.