Director, Grievance and Appeals

Description

COMPANY OVERVIEW

Zing Health is a tech-enabled insurance company making Medicare Advantage the best it can be for those 65-and-over. Zing Health has a community-based approach that recognizes the importance of the social determinants of health in keeping individuals and communities healthy. Zing Health aims to return the physician and the member to the center of the health care equation. Members receive individualized assistance to make their transition to Zing Health as easy as possible. Zing Health offers members the ability to personalize their plans, access to facilities designed to help them better meet their healthcare needs and a dedicated care team. For more information on Zing Health, visit www.myzinghealth.com.

SUMMARY DESCRIPTION:

The Director of Appeals and Grievances has immediate accountability for the operational performance, compliance, and continuous improvement of Provider Claim Disputes, Organizational Appeals, and Organizational Grievances. This role provides hands-on leadership over day-to-day operations while ensuring regulatory compliance with CMS requirements, particularly Medicare Part C and Independent Review Entity (IRE) standards.

The Director is responsible for direct supervision of front-line staff, production oversight, staff performance management, and identifying opportunities for automation and process efficiency. This role operates with broad enterprise visibility and is required to understand and manage upstream and downstream impacts across Utilization Management (UM), Claims Operations, Provider Network, and the Provider Call Center as workflows are refined and optimized.

ESSENTIAL FUNCTIONS:

• •Lead day-to-day operations for Provider Claim Disputes, Organizational Appeals, and Organizational Grievances, ensuring compliance with CMS and state timeliness and accuracy requirements.
• •Directly supervise frontline staff, including daily production monitoring, quality review, coaching, performance management, and corrective action as needed.
• •Own productivity, quality, and compliance outcomes for all in-scope work, using data and metrics to identify risks, trends, and improvement opportunities.
• •Drive operational efficiency through workflow optimization, standardization, and identification of automation opportunities.
• •Maintain advanced knowledge of CMS Medicare Part C requirements, including Independent Review Entity (IRE) processes, and ensure ongoing audit readiness.
• •Ensure policies, procedures, job aids, workflows, and training materials are accurate, current, and effectively implemented.
• •Partner cross-functionally with Utilization Management, Claims Operations, Provider Network, and the Provider Call Center to manage upstream and downstream impacts of process changes.
• •Communicate performance, risks, and improvement initiatives to operational and executive leadership; proactively escalate regulatory or operational concerns.

Requirements

QUALIFICATIONS AND REQUIREMENTS:

JOB REQUIREMENTS:

• •Bachelor’s degree or equivalent relevant experience required.
• •Minimum of eight (8) years of experience in Medicare Advantage operations, with demonstrated leadership responsibility.
• •Minimum of three (3) years of direct management experience in Grievance and Appeals within a managed care environment, including supervision of frontline staff.
• •Advanced knowledge of CMS Medicare regulations, specifically Medicare Part C grievance and appeals requirements and Independent Review Entity (IRE) processes.
• •Demonstrated experience managing production-based teams with defined timeliness and quality metrics.
• •Proven ability to drive staff-level performance management and operational accountability.
• •Experience leading process improvement initiatives, including workflow redesign and automation enablement.
• •Strong understanding of cross-functional health plan operations, including UM, Claims Operations, Provider Network, and Provider Call Center functions.
• •Strong analytical, organizational, and problem-solving skills with the ability to manage competing priorities in a fast-paced, highly regulated environment.
• •Excellent written and verbal communication skills with the ability to present to leadership and regulatory stakeholders.

PREFERED SKILLS

• •Demonstrated experience and comfort using Salesforce as an operational system of record
• •Experience using the Health Rules Payer (HRP) claims adjudication platform

Member-centric Impact Statement:

From the first day of coverage through every claim and service interaction, Zing Core Operations is meant to reduce friction, fix problems quickly, and ensure members get the help and benefits they’ve earned—especially during high-stress moments.

Zing Health offers the following benefits:

• •A competitive salary based on the market
• •Medical, Dental, and Vision
• •Employer-Paid Life Insurance
• •Paid Maternal Leave
• •Paid Paternal Leave
• •401(K) match up to 4%
• •Paid-Time-Off
• •Employee Assistance Programs
• •Several supplemental benefits are available, including, but not limited to, Spouse Insurance, Pet Insurance, Critical Illness coverage, ID Protection, etc.

Zing Health is committed to being an Equal Opportunity Employer. This means the company ensures all employment decisions, including hiring, promotion, compensation, and benefits, are made without regard to race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or any other legally protected characteristic. Zing Health strives to create a diverse, inclusive, and respectful workplace, providing equal access and opportunities for all employees and applicants. The organization actively promotes a culture of fairness and non-discrimination, supporting the personal and professional growth of every team member.