Position Summary

The Appeals & Grievances Lead oversees the daily operations and performance of the Appeals & Grievances program. This role provides subject matter expertise, guidance, and leadership to ensure timely, compliant, and high-quality resolution of appeals and grievances. The Lead serves as a resource in policy and procedure creation while continuously driving process improvements and quality outcomes.

Job Responsibilities

• Oversee workflow management to ensure cases are processed accurately and within required turnaround times
• Ensure compliance with state and federal standards and internal policies
• Serve as a subject matter expert for appeals and grievances policies, regulations, and best practices
• Provide leadership and support to an Appeals & Grievances Coordinator with handling appeals and grievance cases
• Support reporting, quality assurance, performance metrics, and timeliness standards
• Review complex or escalated appeal and grievance determinations
• Identify trends, root causes, and opportunities for process improvement
• Collaborate with cross-functional teams to investigate appeals and grievance cases
• Contribute to policy development, training, and continuous improvement initiatives

Required Qualifications

• Bachelor’s degree in Healthcare Administration, Business, or a related field (or equivalent experience)
• 3-4 years of experience with insurance operations ideally in an appeals and grievances or customer service area
• Strong analytical, organizational, and decision-making skills
• Strong customer service skills and customer service focus
• Ability to work independently and efficiently use technology
• Demonstrate a high degree of good judgement, maturity, and tact to successfully manage member concerns and expectations

Preferred Qualifications

• Knowledge of commercial appeals and grievances regulations and compliance
• Prior supervisory or lead team member experience
• Experience with appeals and grievances tracking systems or case management software
• Prior experience working in a remote environment

The target hiring range for this role is $74,715 - $101,085 ( Annually). The starting base salary will be determined based on skills, experience, and other job-related factors. In addition, our total rewards package includes medical, dental, and vision plans; generous time off including PTO, short and long-term disability insurance and a competitive 401(k) savings match including financial planning workshops. See our Careers Page for more information.

The specific statements shown in each section of this description are not intended to be all-inclusive. They represent typical elements and criteria necessary to successfully perform this position.

** In accordance with Delta Dental of Massachusetts’ Compliance Plan, all employees must conduct Delta Dental of Massachusetts business and activities in accordance with applicable laws, regulations, professional standards, and ethical standards and report potential compliance or ethical issues to Delta Dental of Massachusetts’ designated Compliance Officer. **

Delta Dental of Massachusetts’ Affirmative Action Program affirms our commitment to make reasonable accommodations for 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 and activities. Please see Human Resources for additional information regarding this program.