We enjoy the important work we do every day on behalf of our members.

Job Summary

Under the general direction of the VP, the Appeals and Grievances Director is responsible for management and oversight of the Enterprise Member Appeals and Grievances Department. The Director is responsible for all aspects of the member appeals and grievance processes for all lines of business across the enterprise, including Commercial, Senior Products, Public Plans, joint ventures and other state sponsored products. The Director will be responsible for; directing, leading and modifying the business processes and operations for member appeals and member grievances to ensure compliance with Tufts Health Plan business rules; and develop, implement and refine processes to ensure compliance with relevant regulatory requirements, including but not limited to ACA, CMS, DOI, EOHHS, NCQA and USFHP.

The director works closely with key internal stakeholders such as Medical Directors, Health Care Services, Operations, Marketing, Network Contracting, Legal, Servicing, Claims, Corporate Communications, and Medical Policy. The Director leads staff (managers and program managers) and manages the department budget, develops and executes strategic messaging and represents Tufts Health Plan with outside constituents including providers and regulatory agencies.

Job Description

Requirements

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!.

Tufts Health Plan is an equal opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. For our EEO Policy Statement, please click here. If you d like more information on your EEO rights under the law, please click here.