Director – Grievance & Appeals

This is a fully remote position, open to applicants in Florida.

📋 Description

• Supervise member appeals and grievance processes.

• Lead and ensure effective operational management of appeals and grievance departments/functions.

• Engage in internal committees and contribute to risk assessment activities and regulatory changes.

• Create and implement processes, policies, training, and procedures to ensure regulatory compliance.

• Address performance issues below standards and resolve risk management challenges.

• Monitor and analyze preventable issues and grievances, leading procedural improvement committees.

• Reduce legal and financial risks for providers, employers, and members.

• Assess potential loss and financial risks associated with unusual occurrence cases.

• Recognize the need for in-house legal assistance and collaborate with plan attorneys on litigated cases.

• Assist in overseeing case preparation and research.

• Represent in court for small claims and administrative law judge cases.

• Develop operational budgets along with completing forecasts and variance reports.

• Lead the creation of Business Area Requirement Reports and business cases.

• Offer guidance, policy interpretation, and compliance support throughout the Health Plan.

• Carry out additional duties as necessary.

⛳️ Requirements

• Must be a resident of Florida.

• Bachelor’s Degree in a relevant field or equivalent experience.

• Over 5 years of experience in grievances, appeals, or healthcare law-related domains.

• Prior management experience in managed care operations.

• Experience in leading cross-functional teams on large projects or supervisory experience involving hiring, training, assigning work, and managing staff performance.

• Master's Degree is preferred.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement programs.

• Paid time off plus holidays.

• Flexible work arrangements with options for remote, hybrid, field, or office schedules.

• Additional forms of incentives may be included in total compensation.