Director, Operations, Complaints, Appeals & Grievances

Director, Operations, Complaints Appeals & Grievances

Director, Operations, Complaints, Appeals & Grievances

Who are we?

Versant Health is one of the nation’s leading administrators of managed vision care, serving millions of our clients’ members nationwide. We are driven by our mission to help members enjoy the wonders of sight through healthy eyes and vision.

As a Versant Health associate, you can enjoy a comprehensive Total Rewards package, which includes health and dental insurance, tuition reimbursement, 401(k) with company match, pet insurance, no-cost-to-you vision insurance for you and your qualified dependents. We are also invested in your success. There are many opportunities for advancement and development throughout all stages of your career with us.

See how you can make a difference with the support of strong leadership and a team environment.

See Everything, Be Anything™.

What are we looking for?

The Director, Complaints, Appeals and Grievances oversees the complaints, appeals, and grievances program within the organization. The position leads a team of professionals dedicated to maintaining high standards of customer service, quality and satisfaction. The position ensures compliance with regulatory, contractual, and legal requirements as well as internal policies. The position develops and implements strategies to improve the efficiency and effectiveness of the complaints, appeals, and grievances process to drive continuous quality improvement and the reduction and elimination of complaints, appeals, and grievances. The position ensures the program is reflective of the Versant Health brand strategy and customer first culture

Where you will have an impact

Leadership and Management

• Provide leadership, guidance, and support to team members.
• Direct and manage the complaints, appeals, and grievances department.
• Develop and monitor performance metrics to ensure departmental goals
  
  

including regulatory and contractual SLAs are met.

• Participate and lead in the development of associates skills and capabilities
• In partnership with Management, develop and manage overall forecast, budget,
  
  

and staffing models to meet evolving business needs.

• Support and lead special projects as assigned or necessary.
  
  

Compliance and Quality Assurance

• Ensure all complaints, appeals, and grievances are overseen in compliance
  
  

with state and federal regulations to include partnership with applicable areas

to integrate required changes into policies and systems.

• Conduct regular audits and reviews to maintain quality standards.
• Develop and implement corrective actions as necessary to address any
  
  

compliance or contractual issues.

Process Improvement

• Identify opportunities for process improvements and implement changes to
  
  

enhance efficiency.

• Develop, implement, and maintain policies and procedures related to
  
  

complaints, appeals, and grievances.

• Collaborate with other departments to streamline processes and improve
  
  

overall customer experience.

Reporting and Analysis

• Prepare and present regular reports on departmental performance to senior
  
  

management.

• Analyze trends and data to identify areas for improvement to reduce and
  
  

eliminate complaints, appeals, and grievances.

• Provide insights and recommendations based on data analysis to reduce risk
  
  

and drive a more positive customer experience.

• Monitor department quality and production results to drive continuous
  
  

improvement and efficiency within the program.

Competencies

• Strong leadership skills with the ability to inspire and motivate a team.
• Excellent decision-making and problem-solving abilities.
• Proven ability to lead cross-functional initiatives and drive results.
• Proven ability to take accountability for the development of processes and procedures to support enhanced customer service and effective work.
• Strong analytical skills with the ability to interpret data and make informed decisions.
• Proficiency in using data analysis tools and software.
• Ability to think critically, focus on a problem and consider all aspects to arrive at a solution.
• Deep commitment to customer satisfaction and service excellence.
• Ability to handle sensitive and complex customer issues with empathy and professionalism.
• Extensive experience in interfacing with customer, clients, and regulators.
• In-depth knowledge of state and federal regulations related to complaints, appeals, and grievances.
• Ability to stay current with regulatory changes and ensure compliance.
  
  

What’s necessary to do the job?

• Bachelor’s degree in Business Administration, HealthCare Management, or a
  
  

related field required or equivalent combination of experience and education

• Minimum of 5 years of experience in complaints, appeals, and grievances or
  
  

compliance management

• Minimum of 5 years in a leadership role within a healthcare or insurance setting
  
  

(vision Experience Preferred)

• Proven track record of managing complex processes and leading teams to
  
  

achieve high performance in a regulated environment

HIPAA & Security Requirements

All Associates must comply with the Health Insurance Portability Accountability Act of 1996 (HIPAA) as it pertains to disclosures of protected health information (PHI) as described in the Notice of Privacy Practices and HIPAA Privacy Policies and Procedures. As a component of job roles and responsibilities, Associates may have access to covered information, cardholder data or other confidential customer information which must be protected at all times. As a result, Associates must explicitly adhere to all data security guidelines established within the Company’s Privacy & Security Training Program.

Versant Health will never request money from candidates who seek employment with us and will never ask for any payment as part of the recruitment process.

Versant Health is a proud Equal Employment Opportunity and Affirmative Action employer dedicated to attracting, retaining, and developing a diverse and inclusive workforce. All qualified applicants will receive consideration for employment at Versant Health without regards to race, color, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, age, disability, national origin, marital or domestic/civil partnership status, genetic information, citizenship status, uniformed service member or veteran status, or any other characteristic protected by law.

The wage range for applicants for this position is [$150,000.00 to $160,000.00].

All incentives and benefits are subject to the applicable plan terms.