Director, Complaints Grievance & Appeals

About the role

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. DentaQuest 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.

Responsibilities

• 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.

Requirements

• 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.