Associate Director – Appeals & Grievances

This is a fully remote position, open to applicants in Arizona, +16 more states.

📋 Description

• Direct operational objectives for the CGA and Escalation teams, ensuring accountability for compliance and quality metrics across all business sectors.

• Cultivate managers, leads, and specialists through structured coaching frameworks and performance accountability.

• Act as the resolution authority for significant, high-risk administrative complaints from senior leadership, regulatory bodies, and social media channels.

• Create and enforce standardized evaluation, escalation, and resolution processes.

• Ensure audit readiness and serve as the primary operational lead for CMS, state Department of Insurance (DOI), and internal compliance audits.

• Collaborate with Claims, Network, Legal, and Compliance teams to transform case data insights into systemic root-cause solutions.

• Utilize workforce data, capacity staffing models, and Lean methodologies to enhance operational efficiency and cost-effectiveness.

• Oversee delegated vendor entities to ensure adherence to contractual, regulatory, and quality CGA standards.

• Present performance metrics, operational trends, and strategic compliance recommendations to executive leadership.

• Adhere to all applicable laws and regulations.

• Execute other assigned responsibilities.

⛳️ Requirements

• Minimum of 7 years of progressive experience in healthcare operations, particularly in healthcare compliance, complaints, grievances, or appeals (A&G).

• At least 4 years of experience in people management, including leading and developing supervisors, team leads, or managers in a high-volume operations setting.

• Advanced knowledge and relevant experience with Commercial Insurance, Medicare/Medicaid, and Affordable Care Act (ACA) regulations related to administrative Grievance & Appeals processes.

• Experience in leading or representing operational teams during CMS, state-level, or other regulatory audits.

• Proficient in using operational data to drive decision-making, manage capacity, and implement process enhancements.

• Bachelor’s Degree or 4 years of equivalent experience.

• Operational Excellence Certification (Lean Six Sigma Green/Black Belt or equivalent).

• Experience in leading remote or multi-site teams in a collaborative, fast-paced environment.

• Familiarity with data visualization tools (Tableau, Looker) and specialized case management systems (such as Inovaare or Jira).

• Advanced Degree (MBA, Master of Health Administration, or Juris Doctor).

🏝️ Benefits

• Employee benefits.

• Unlimited vacation program.

• Annual performance bonuses.

• Medical benefits.

• Dental benefits.

• Vision benefits.

• 11 paid holidays.

• Paid sick time.

• Paid parental leave.

• 401(k) plan participation.

• Life insurance.

• Disability insurance.

• Paid wellness time and reimbursements.

• Remote work from a home office.

• Occasional travel for team meetings and company events.