Director, Complaints Grievance & Appeals

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.

At Sun Life, we're driven by our

Purpose:

helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful.

When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives.

Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities.

Location: Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work. Our team members and leaders are expected to foster connection and teamwork by being present in the office at least 2 days per week.

The Director, Complaints, Grievances & Appeals (CG&A) is responsible for directing CG&A operations as well as the training and reporting functions for CG&A. This role is required to participate in client audits, presentations, implementations, corrective action plans, develop and implement process improvements, as well as meet client requirements in regards to contractual turnaround times. The Director is responsible for guiding and motivating team members and completing performance and wage evaluations of staff.

This individual will also be required to establish a data driven operating model that will determine the ongoing costs of the CG&A function and the associated strategy and tactics to develop a more efficient and effective operating model.

• Establish the strategic direction of the CG&A function including tactics to improve employee engagement, customer satisfaction and operational efficiency.
• Monitor daily and monthly turnaround time to ensure compliance with client contract requirements
• Complete, communicate, and interpret monthly reporting requirements and if necessary proactively develop action plans to address any gaps or potential deficiencies
• Ensure department is meeting client expectations and terms of contract requirements, State Laws/Regulations, CMS and NCQA guidelines
• Develop, create, and update department policies, procedures and processes to ensure compliance with State Laws/Regulations, CMS and NCQA guidelines
• Develop and implement root cause resolutions to internal and external operational and personnel issues
• Oversee and direct the development of training materials and training of departmental on guidelines and processes
• Identify, develop, implement, quantify and report on efficiencies in the workflow of the department.
• Participate in and complete client audits both on site and off site if needed
• Develop, implement and maintain a strategic and consistent process for Corrective Action Plans (CAP) and perform root cause analysis
• Participate in business implementation projects. Act as the Subject Matter Expert (SME) for CGA
• Build an annual budget that is data based and identify and establish processes that will enhance the efficiency of the operation.
• Performance management of CGA staff.
• Adhere to business processes
• Other duties as needed or required.

• 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 Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) and State Medicaid/Commercial regulations or compliance requirements and differences amongst the requirements based on Product type
• Excellent verbal and written communication skills required with attention to detail
• Excellent analytical skills required.
• Previous experience presenting to high-level management and/or external constituents required
• Excellent presentation and interpersonal skills required
• Extensive knowledge of general computer software required. (Excel, MS Word, and…