Director, Complaints Grievance & Appeals

Location: Wellesley Hills

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. Denta Quest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.

Job Description:

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 opportunity:

 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.  How you will contribute: 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…