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Director, Appeals and Grievances

625 State St, Schenectady, NY 12305, USA Req #2608

Friday, May 16, 2025

At MVP Health Care, we’re on a mission to create a healthier future for everyone – which requires innovative thinking and continuous improvement. To achieve this, we’re looking for a Director, Appeals & Grievances to join #TeamMVP. This is the opportunity for you if you have a passion for health equity, transformation & being the difference for the customer.

What’s in it for you:

+ Growth opportunities to uplevel your career

+ A people-centric culture embracing and celebrating diverse perspectives, backgrounds, and experiences within our team

+ Competitive compensation and comprehensive benefits focused on well-being

+ An opportunity to shape the future of health care by joining a team recognized as a **Best Place to Work For in the NY Capital District** , one of **the Best Companies to Work For in New York** , and an **Inclusive Workplace** .

Qualifications you'll bring** **:

+ 4-year undergraduate degree.

+ 5 years’ related experience. Previous customer service experience preferably in health insurance, HMO, or appeals environment. Demonstrated leadership skills, including the abilities to motivate, develop, and support a team of staff

+ Experience leading and managing projects and policy and procedure changes, including coordination of activities and initiatives across departments

+ Demonstrated ability to work in a fast-paced environment and manage staff to both meet and exceed goals and key performance measures

+ Passionate about customer service with a continuous improvement mindset

+ Excellent problem solving, trend identification, and analytical skills, with a demonstrated ability to solve problems effectively and efficiently

+ Ability to advance ideas even in the face of resistance and act as a change agent

+ Commitment to high ethical standards in all work; protects the privacy of members and MVP data and exercises discretion in handling confidential member information

+ Excellent oral and written communication skills, including presentation skills

+ Demonstrated PC skills using Microsoft applications

+ Ability to travel to other office locations

+ Willingness to work a flexible schedule

+ Curiosity to foster innovation and pave the way for growth

+ Humility to play as a team

+ Commitment to being the difference for our customers in every interaction

Your key responsibilities:

+ Oversee the development, training, and performance management of a team that will report across the grievance and appeals department

+ Conduct audits and recommended process improvements that address organizational non-compliance and lead to passing all DOH surveys, while avoiding any sanctions

+ Implement programs and technology to improve member engagement; leverage internal resources and enhance member outreach processes that eliminate case backlog

+ Ability to track appeals and grievances and evaluate present and potential future resources to successfully implement and manage timely resolution

+ Collaborate with provider relations and claims teams as well as Medical Directors, Pharmacy Benefits Managers, and third-party administrators to achieve resolution of appeals and grievances

+ Manage the development of data collection and reporting systems to capture grievances and appeals data in line with CMS and DOH reporting regulations.

+ Spearhead any investigations and prepare recommended responses to grievances referred to the plan from regulatory entities including but not limited to the DOH, CMS and Department of Financial Services

+ Develop standards and criteria for monitoring compliance with regulatory requirements and professional standards across all programs

+ Other duties as assigned by leadership **.**

+ Contribute to our humble pursuit of excellence by performing various responsibilities that may arise, reflecting our collective goal of enhancing healthcare delivery and being the difference for the customer.

Where you'll be** **:

Virtual, with the ability to travel to HQ for team meetings, as necessary.

Pay Transparency

MVP Health Care is committed to providing competitive employee compensation and benefits packages. The base pay range provided for this role reflects our good faith compensation estimate at the time of posting. MVP adheres to pay transparency nondiscrimination principles. Specific employment offers and associated compensation will be extended individually based on several factors, including but not limited to geographic location; relevant experience, education, and training; and the nature of and demand for the role.

We do not request current or historical salary information from candidates.

MVP's Inclusion Statement

At MVP Health Care, we believe creating healthier communities begins with nurturing a healthy workplace. As an organization, we strive to create space for individuals from diverse backgrounds and all walks of life to have a voice and thrive. Our shared curiosity and connectedness make us stronger, and our unique perspectives are catalysts for creativity and collaboration.

MVP is an equal opportunity employer and recruits, employs, trains, compensates, and promotes without discrimination based on race, color, creed, national origin, citizenship, ethnicity, ancestry, sex, gender identity, gender expression, religion, age, marital status, personal appearance, sexual orientation, family responsibilities, familial status, physical or mental disability, handicapping condition, medical condition, pregnancy status, predisposing genetic characteristics or information, domestic violence victim status, political affiliation, military or veteran status, Vietnam-era or special disabled Veteran or other legally protected classifications.

To support a safe, drug-free workplace, pre-employment criminal background checks and drug testing are part of our hiring process. If you require accommodations during the application process due to a disability, please contact our Talent team at [email protected] .

Other details

+ Job Family Medical Management/Clinical

+ Pay Type Salary

+ Min Hiring Rate $133,000.00

+ Max Hiring Rate $155,000.00

+ 625 State St, Schenectady, NY 12305, USA

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