Grievance and Appeals Director

Grievance And Appeals DirectorThe Grievance and Appeals Director provides strategic leadership and operational oversight for Delta Dental's Grievance and Appeals (G&A) function. This role is responsible for the development, execution, and continuous evolution of the department's strategy, ensuring all grievance, appeal, and regulatory complaint activities are compliant, efficient, and aligned with enterprise objectives.Leading a large, high-performing organization, the Director will guide and develop the G&A leadership team while ensuring adherence to complex state and federal regulatory requirements. This role partners closely with cross-functional stakeholders to analyze complaint and appeal trends, identify root causes, and drive enterprise-wide improvements that enhance both patient and provider experiences.ResponsibilitiesProvide strategic direction and oversight of all G&A operations, ensuring compliance with regulatory requirements (e.g., CMS, DHCS, DMHC, NCQA) and internal standardsEnsure departmental processes align with Quality Improvement program requirements, accreditation standards, and audit expectationsLead cross-functional collaboration to identify trends, root causes, and opportunities for continuous improvement based on grievance and appeals dataDrive execution of enterprise initiatives by aligning stakeholders, measuring outcomes, and communicating insights and recommendationsDesign and optimize organizational structure to support performance, scalability, and efficient resource utilizationServe as Chair of the Grievance Insight Committee, delivering data-driven recommendations and strategic guidanceFoster a high-performing, engaged culture that promotes accountability, transparency, and employee satisfactionOversee department budgeting and financial performance, identifying variances and implementing corrective actionsDevelop and implement policies, procedures, and workflows that ensure compliance while improving operational efficiencyLead all audit-related activities, including preparation, execution, corrective action planning, and regulatory follow-upQualifications8+ years of experience in healthcare operations (G&A experience not required)3+ years of leadership experience overseeing large-scale teams (150+ employees)Proven ability to lead, develop, and influence leaders and teams in a complex, matrixed environmentStrong executive presence with the ability to build partnerships and influence at all levels, including C-suiteDemonstrated ability to translate complex data, trends, and processes into clear, actionable insightsExperience developing strategy and driving execution with measurable outcomesStrong critical thinking, problem-solving, and analytical capabilitiesExcellent organizational and time management skills, with the ability to manage multiple prioritiesKnowledge of healthcare operations and provider network environmentsKnowledge of quality improvement methodologies (e.g., Lean Six Sigma)Exceptional communication and negotiation skills across diverse and cross-functional teamsAbility to travel up to 25% as neededBase Pay Information The national base pay range at the end is a good-faith estimate of what Delta Dental may pay for new hires. Actual pay may vary based on Delta Dental's assessment of the candidate's knowledge, skills, abilities (KSAs), related experience, education, certifications, and the ability to meet required minimum job qualifications. Other factors impacting pay include prevailing wages in the work location and internal equity.Pay Grade 24. $122,400 - $265,100Additional InformationBehind the smile! We are dedicated to safeguarding the health and financial stability of our employees and their loved ones. This commitment extends beyond the workplace to foster personal growth and holistic wellbeing. Our life-changing rewards package includes:Competitive base and incentive pay401(k) with robust matching and non-matching contributionsRich medical & pharmacy benefits100% employer-paid dental and vision benefitsHolistic wellbeing program with deep financial incentivesGenerous paid time off plus 12 paid holidays and your birthday offCulture of growth and learning: career development; tuition reimbursement; recognition programFamily support: adoption assistance, fertility treatment, child, elder & pet care assistanceSocial responsibility and volunteer opportunitiesEmployee discount programFair Chance Ordinances and Criminal Background Considerations This position requires that the applicant undergo a background check. Qualified applicants with arrest or conviction records will be considered for employment in accordance with any applicable federal, state or local laws, including, but not limited to, the California Fair Chance Act, the Los Angeles County Fair Chance Ordinance, the City of Los Angeles Fair Chance Initiative for Hiring Ordinance, the San Francisco Fair Chance Ordinance, and/or New York Corrections Law Article 23-A. Important Work Authorization Information Please note, Delta Dental will not sponsor applicants for work visas for this position. #LI-HybridAbout the TeamAt Delta Dental, we're behind millions of smiles and counting. For over 68 years, we've served our communities by increasing access to affordable, quality care but that commitment to care extends beyond the people we serve, to the dedicated employees who make those smiles genuine. We've come this far by building fair programs that offer opportunities for advancement, create meaningful connections and improve the lives of our employees and their families. Because we know that when we take exceptional care of each other, we can make a positive impact for all. We champion an inspirational workplace through our commitment to trust, service, excellence and innovation. Joining us means working for a company that offers stability and balance, opportunities for leadership at all levels, and a work environment focused on teamwork and camaraderie. Discover the smiling faces behind Delta Dental and experience our values and culture in action by connecting with us on social media.Job InfoJob Identification 3204Job Category Grievance & AppealsJob Schedule Full timeLocations San Francisco, CA, United States Oakland, CA, United States Rancho Cordova, CA, United States Camp Hill, PA, United States Alpharetta, GA, United States (Hybrid)