Director Grievances & Appeals

Job description

The Director of Grievance and Appeals assumes leadership for the program development and strategic planning of the Delta Dental Grievance and Appeals Department. This role guides and develops the G&A leadership team ensuring that all operations, including the processing of appeals, grievances, and regulatory complaints, meet compliance standards and adherence to multiple state and federal -mandated standards, guidelines and reporting requirements. The Director works closely with various stakeholders to identify trends in complaints and makes recommendations that will improve the patient and provider experience. - Directs and oversees department strategy, operations and compliance with regulatory-required (e.g., CMS, DHCS, DMHC and NCQA) grievance and appeals processes, protocols, and activities. - Ensures that department processes and procedures support overall Quality Improvement program requirements and meet accreditation, audit and Company standards. - Leads collaborative efforts with enterprise departments to continuously pursue opportunities for improvement that stem from grievance data and appeals trends. - Leads cross-functionally to ensure that initiatives are executed succ...