Director, Appeals and Grievance

Plan, develop, and direct department services and activities for all existing and new business opportunities, including setting strategic long-term goals for Commercial, Medicaid, and Medicare lines. Develop policies, workflows, and compliance documents meeting contractual, regulatory, and accreditation requirements. Provide oversight for complaints, appeals, and grievances reporting while interfacing with Member Services on key performance indicators. Oversee staff to resolve ad hoc requests and coordinate resources for state, federal, and accreditation mandates. Collaborate with Medical Directors to identify trends and recommend changes to medical criteria and benefit items. Manage external audits for NCQA, EQRO, CMS, DMAS, and BOI, ensuring full compliance with department SLAs and targets. Support inquiries from Compliance and Internal Audit by developing corrective action plans focused on recurrence avoidance.