VP, Provider and Member Appeals, Grievances

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

📋 Description

• Create and uphold the strategic roadmap for the member and non-contracted provider appeals program.

• Establish a governance framework, oversight routines, and operational policies to ensure compliance with CMS Parts C & D, state laws, audit preparedness, and internal quality standards.

• Lead the organizational design and workforce structure for comprehensive functionality.

• Manage daily operations and staff oversight of appeals and grievance intake, routing, clinical evaluations, payment dispute resolutions, escalation procedures, and final determination issuance.

• Guarantee that appeals and grievances are resolved within all CMS-mandated timeframes and internal service level agreements (SLAs).

• Collaborate with Compliance and Legal teams to interpret regulatory changes and integrate them into review and documentation policies.

• Develop and enforce quality standards for review accuracy, rationale for decisions, and completeness of documentation.

• Lead and nurture a multi-tiered leadership team, including Directors, Senior Managers, and Managers responsible for daily operations.

• Set standards for decision quality and act as a subject matter expert for intricate cases.

⛳️ Requirements

• Over 10 years of progressive leadership experience in appeals, grievances, utilization management, or health plan regulatory operations.

• Minimum of 5 years in a senior leadership position overseeing a multi-functional team within a Medicare Advantage or Health Insurance context.

• Profound understanding of CMS Medicare Advantage Part C requirements and appeal decision criteria.

• Extensive experience in case reviews, documentation, and formulating defensible rationales.

• Exceptional clinical and/or analytical judgment along with the ability to interpret medical records.

• Experience in writing or reviewing medical necessity determinations or complex claim appeals.

• Previous involvement in or preparation for CMS or NCQA audits.

• Bachelor’s degree in Healthcare Administration, Business, or a related field.

🏝️ Benefits

• Health insurance

• Professional development opportunities