Vice President of Appeals and Grievances

Job Summary

Providing strategic leadership in a fully remote capacity, the Vice President of Appeals and Grievances will manage the operational, regulatory, and performance aspects of provider and member appeals, ensuring compliance with CMS regulations and driving organizational excellence.

Key Responsibilities

• Develop and maintain the strategic roadmap for the appeals program, ensuring compliance with Medicare Advantage regulations
• Oversee daily operations of appeals and grievance processes, ensuring timely resolution within mandated timeframes
• Serve as the primary organizational representative to CMS and regulatory bodies regarding appeals and grievances performance

Required Qualifications

• 10+ years of leadership experience in appeals, grievances, or health plan regulatory operations, with at least 5 years in a senior leadership role
• Deep understanding of CMS Medicare Advantage Part C requirements and appeal decision standards
• Bachelor's degree in Healthcare Administration, Business, or a related field
• Strong experience in case review and writing defensible rationales for medical necessity determinations
• Exceptional leadership and cross-functional collaboration skills