DescriptionPOSITION OVERVIEW
Harbor Health is seeking an experienced Appeals & Grievances Director to lead the health plan's appeals and grievances function. In this role, you will oversee the intake, investigation, and timely resolution of member and provider appeals and grievances across Harbor Health's Texas markets, ensuring full compliance with CMS, Texas Department of Insurance (TDI), and NCQA requirements. You will lead a team of appeals and grievance professionals, partner closely with Compliance, Legal, Clinical, Claims, and Member Services, and serve as a key voice for member advocacy within Harbor Health's payvider model, where an integrated medical group and health plan work together to deliver member-centered care.
POSITION DUTIES & RESPONSIBILITIES
Program Leadership & Oversight
- Own the end-to-end appeals and grievances program, including policies, standard operating procedures, and workflow design.
- Ensure all appeals and grievances are resolved within CMS, TDI, and state-mandated timeframes, escalating urgent or expedited cases appropriately.
- Partner with Medical Directors on clinical appeal reviews, including coordination of peer-to-peer and independent review organization (IRO) referrals.
- Establish quality controls and case-review processes to ensure consistent, well-documented, and legally sound determinations.
Regulatory Compliance & Reporting
- Maintain deep working knowledge of CMS Medicare Advantage appeals and grievance regulations, TDI requirements, ACA regulations, and NCQA/URAC accreditation standards.
- Prepare and submit required regulatory reporting, including CMS Part C/D universes, HPMS submissions, and TDI complaint reporting.
- Serve as the appeals and grievances subject-matter expert during regulatory audits, NCQA surveys, and delegation oversight reviews.
- Monitor evolving regulatory guidance and update policies, training, and workflows proactively.
Team Leadership & Development
- Hire, coach, and manage a team of appeals and grievance coordinators/specialists, setting clear performance expectations and development plans.
- Build training programs and quality-assurance processes to support consistent, member-centered casework.
- Foster a culture of accountability, empathy, and continuous improvement within the team.
Cross-Functional Collaboration & Insights
- Partner with Compliance, Legal, Claims, Clinical, and Member Services to resolve complex or cross-functional cases.
- Analyze appeals and grievance trends to identify root causes and recommend process, policy, or claims-adjudication improvements.
- Provide regular reporting and insights to health plan leadership on volume, turnaround times, overturn rates, and member experience impact.
- Oversee any delegated appeals and grievance functions, including vendor performance monitoring and corrective action planning as needed.
DESIRED PROFESSIONAL SKILLS & EXPERIENCE
- Bachelor's degree required; Master's degree in healthcare administration, business, or related field preferred.
- 7+ years of progressive experience in health plan appeals and grievances, regulatory compliance, or member services, including at least 3 years in a people-leadership role.
- In-depth knowledge of CMS Medicare Advantage appeals/grievance regulations, TDI requirements, ACA regulations, and NCQA/URAC standards.
- Experience with Medicare Advantage, Medicaid, and/or Marketplace appeals and grievances strongly preferred.
- Proven ability to lead teams through high case volumes and tight regulatory deadlines while maintaining quality and member empathy.
- Strong analytical skills, with experience using case-management or tracking systems and translating case data into process improvements.
- Excellent written and verbal communication skills, including experience drafting formal appeal/grievance determination letters.
- Comfortable operating in a fast-paced, growth-stage payvider environment spanning both health plan and clinical operations.
WHAT WE OFFER
- Competitive base salary and annual bonus eligibility.
- Comprehensive medical, dental, and vision benefits.
- 401(k) with company match.
- Generous PTO and paid holidays.
- Collaborative and dynamic work environment within an innovative, integrated payvider model.
- Professional development and growth opportunities.
- A transparent and unique culture focused on member-centered care.
