Director, Complaints Grievance & Appeals

Sun Life U.S. is one of the largest providers of employee and government benefits, helping approximately 50 million Americans access the care and coverage they need. Through employers, industry partners and government programs, Sun Life U.S. offers a portfolio of benefits and services, including dental, vision, disability, absence management, life, supplemental health, medical stop-loss insurance, and healthcare navigation. We have more than 6,400 employees and associates in our partner dental practices and operate nationwide.At Sun Life, we're driven by our Purpose: helping our Clients achieve lifetime financial security and live healthier lives. Our values shape how we work: caring, authentic, bold, inspiring, and impactful.When you join Sun Life, you'll work with passionate colleagues and empowering leaders who support your growth and celebrate your contributions, so you can make a meaningful difference in our Clients' lives.Visit our website to discover how Sun Life is making life brighter for our customers, partners and communities. DentaQuest manages dental and vision benefits for more than 33 million Americans. Our outcomes-based, cost-effective solutions are designed for Medicaid and CHIP, Medicare Advantage, small and large businesses, and individuals. With a focus on prevention and value, we aim to make quality care accessible to improve the oral health of all.Job Description: Location: Sun Life embraces a hybrid work model that balances in-office collaboration with the flexibility of virtual work. Our team members and leaders are expected to foster connection and teamwork by being present in the office at least 2 days per week.The opportunity: The Director, Complaints, Grievances & Appeals (CG&A) is responsible for directing CG&A operations as well as the training and reporting functions for CG&A. This role is required to participate in client audits, presentations, implementations, corrective action plans, develop and implement process improvements, as well as meet client requirements in regards to contractual turnaround times. The Director is responsible for guiding and motivating team members and completing performance and wage evaluations of staff. This individual will also be required to establish a data driven operating model that will determine the ongoing costs of the CG&A function and the associated strategy and tactics to develop a more efficient and effective operating model. How you will contribute: Establish the strategic direction of the CG&A function including tactics to improve employee engagement, customer satisfaction and operational efficiency.Monitor daily and monthly turnaround time to ensure compliance with client contract requirementsComplete, communicate, and interpret monthly reporting requirements and if necessary proactively develop action plans to address any gaps or potential deficienciesEnsure department is meeting client expectations and terms of contract requirements, State Laws/Regulations, CMS and NCQA guidelinesDevelop, create, and update department policies, procedures and processes to ensure compliance with State Laws/Regulations, CMS and NCQA guidelinesDevelop and implement root cause resolutions to internal and external operational and personnel issuesOversee and direct the development of training materials and training of departmental on guidelines and processesIdentify, develop, implement, quantify and report on efficiencies in the workflow of the department.Participate in and complete client audits both on site and off site if neededDevelop, implement and maintain a strategic and consistent process for Corrective Action Plans (CAP) and perform root cause analysisParticipate in business implementation projects. Act as the Subject Matter Expert (SME) for CGABuild an annual budget that is data based and identify and establish processes that will enhance the efficiency of the operation.Performance management of CGA staff.Adhere to business processesOther duties as needed or required.What you will bring with you: Required:7+ years’ experience of managing in healthcare or related experience required7+ years of previous leadership requiredBachelor degree in related field or related experience requiredAbility to travelRequires knowledge of Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA) and State Medicaid/Commercial regulations or compliance requirements and differences amongst the requirements based on Product typeExcellent verbal and written communication skills required with attention to detailExcellent analytical skills required.Previous experience presenting to high-level management and/or external constituents requiredExcellent presentation and interpersonal skills requiredExtensive knowledge of general computer software required. (Excel, MS Word, and Outlook)Preferred:Knowledge of clinical and industry terminology and procedures preferred.PHYSICAL DEMANDS:Ability to work in a fast-paced environment with multiple interruptionsAbility to communicate in an active office environment.Ability to efficiently operate all job-related office equipment.Ability to communicate via telephone.Ability to sit for 80% or more of an 8-hour workday.Ability to read and view computer screen.The area is located in a wheelchair accessible building.The office environment is active with high voice levels and interruptions that may challenge hearing and concentration.Ability to travelSalary: $114,600 - 171,900At our company, we are committed to pay transparency and equity. The salary range for this role is competitive nationwide, and we strive to ensure that compensation is fair and equitable. Your actual base salary will be determined based on your unique skills, qualifications, experience, education, and geographic location. In addition to your base salary, this position is eligible for a discretionary annual incentive award based on your individual performance as well as the overall performance of the business. We are dedicated to creating a work environment where everyone is rewarded for their contributions.Not ready to apply yet but want to stay in touch? Join our talent community to stay connected until the time is right for you! We are committed to fostering an inclusive environment where all employees feel they belong, are supported and empowered to thrive. We are dedicated to building teams with varied experiences, backgrounds, perspectives and ideas that benefit our colleagues, clients, and the communities where we operate. We encourage applications from qualified individuals from all backgrounds.Life is brighter when you work at Sun LifeAt Sun Life, we prioritize your well-being with comprehensive benefits, including generous vacation and sick time, market-leading paid family, parental and adoption leave, medical coverage, company paid life and AD&D insurance, disability programs and a partially paid sabbatical program. Plan for your future with our 401(k) employer match, stock purchase options and an employer-funded retirement account. Enjoy a flexible, inclusive and collaborative work environment that supports career growth. We’re proud to be recognized in our communities as a top employer. Proudly Great Place to Work Certified in Canada and the U.S., we’ve also been recognized as a "Top 10" employer by the Boston Globe's "Top Places to Work" for two years in a row. Visit our website to learn more about our benefits and recognition within our communities.We will make reasonable accommodations to the known physical or mental limitations of otherwise-qualified individuals with disabilities or special disabled veterans, unless the accommodation would impose an undue hardship on the operation of our business. Please email View email address on click.appcast.io to request an accommodation.For applicants residing in California, please read our employee California Privacy Policy and Notice.We do not require or administer lie detector tests as a condition of employment or continued employment.Sun Life will consider for employment all qualified applicants, including those with criminal histories, in a manner consistent with the requirements of applicable state and local laws, including applicable fair chance ordinances.All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.Job Category: Customer Service / OperationsPosting End Date: 15/11/2026SummaryLocation: Milwaukee, Wisconsin; Baltimore, Maryland; Hartford, CT Office; Portland, ME; Wellesley Hills, Massachusetts; Kansas City, Missouri; Nashville, TennesseeType: Full time