VP, Grievance & Appeals

Job title: VP, Grievance & Appeals

Summary of Position:

• Lead the enterprise, multi-state Grievances and Appeals operations to ensure accurate and timely decisions for members and providers regarding clinical and administrative appeals, payment disputes, and complaints related to quality of service and experience.
• Develop, maintain, and ensure production and quality standards are met, while achieving strong audit outcomes.
• Establish and implement policies and procedures, evaluating them regularly to ensure alignment with regulatory requirements, contractual obligations, and business goals.
• Ensure full compliance with all state and federal appeals and grievances regulations through effective monitoring and quality programs.
• Identify trends across internal and delegated Grievance & Appeals units; develop action plans to address process or systemic failures. Drive cross-functional collaboration with operations, product, clinical, vendor, and executive teams to determine and execute improvements.
• Provide operational oversight across Membership, Provider Network Operations, Claims, Customer Service, Utilization Management Operations, Pharmacy Operations, and Grievance & Appeals—both delegated and internal—to improve performance, member/provider satisfaction, and STAR ratings.
• Partner with executive leadership to ensure clinical programs are implemented in accordance with medical policy and regulatory timeframes, contributing to improved medical expense ratios.
• Serve as the primary liaison with key regulatory agencies, including CMS, DOH, DOL, DFS, NCQA, and the Attorney General.
• Lead the Operations Business Support team in implementing and maintaining business, accreditation, contractual, and regulatory requirements across internal teams and delegates.
• Manage complex enterprise implementations to meet business and compliance outcomes.
• Collaborate with operational leads and business partners to develop effective monitoring plans aligned with compliance standards.
• Lead the coordination and response to all internal, client, and regulatory audits within Operations. Oversee timely and high-quality submission of deliverables including universes and corrective action plans.
• Direct pharmacy operations to ensure optimal service to members and providers for pharmacy benefits.
• Maintain a best-in-class contact center, meeting or exceeding service level expectations and ensuring efficiency and effectiveness via KPI-driven management.
• Leverage innovative technology solutions to enhance responsiveness to customer inquiries.
• Provide strategic and budgetary leadership as part of annual planning.

Principal Accountabilities:

• Develop long-term strategic initiatives providing enterprise-level direction.
• Monitor and communicate competitive trends and capabilities enterprise-wide.
• Contribute significantly to strategic initiatives while delivering efficient, cost-effective operations.
• Recruit, develop, and retain high-performing teams with a strong leadership pipeline and succession planning.
• Act as a change agent to drive organizational transformation and execution of deliverables.
• Deliver 5 STAR performance in Grievance & Appeals, ensuring timely and compliant decision-making.
• Foster a high-performance culture of self-directed teams and continuous improvement.

Education, Training, Licenses, Certifications:

• Bachelor’s degree in a related field required; Master’s degree preferred.

Relevant Work Experience, Knowledge, Skills, and Abilities:

• 12–15+ years of progressive experience in managed care, with a focus on operations, customer service, and grievance & appeals.
• Proven experience managing diverse and remote teams across multiple locations.
• Demonstrated ability to lead corporate-wide initiatives, gain stakeholder buy-in, delegate effectively, and hold teams accountable.
• Strong knowledge of federal, state, and local guidelines governing member and provider processes.
• Track record of developing performance metrics and analytics to drive outcomes.
• Experience in cost containment within large-scale operations.
• Excellent communication and presentation skills, with the ability to engage across all organizational levels.
• Proficient in MS Office tools including Word, Excel, PowerPoint, Outlook, Teams, and SharePoint.
• Strong stakeholder engagement and collaboration skills.

 We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws