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Point32Health Director, Appeals & Grievances in Canton, Massachusetts

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities. To learn more about who we are at Point32Health, click here ( .

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 Point32Health 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 Point32Health with outside constituents including providers and regulatory agencies.

Key Responsibilities/Duties – what you will be doing

  • The Director is responsible for leading the Appeals and Grievance Department management team and provides oversight for the day-to-day act ivies of the complex operations of the Appeals and Grievance Department.

  • Monitor quality and production standards by the interpretation of data and metrics associated with production turnaround times.

  • Oversee development and monitoring of annual compliance plan

  • Oversee implementation of regulatory requirements and changes

  • Oversee timely submission of regulatory reporting requirements

  • Implement policy recommendations with regards to new Plan benefits.

  • Oversee Appeals and Grievances CMS star performance

  • Develop, review, revise and monitor policies and procedures to ensure that all work of the Appeals and Grievances Department meets all regulatory and accrediting standards

  • Manage special departmental projects.

  • Manage the function of analyzing metric driven data to determine the impact of Plan policies and benefits upon the Plan, providers, membership, and groups.

  • Direct staff in data analysis to determine the impact of benefit structure on utilization trends.

  • Direct staff in determining the cost effectiveness of selected contracted services consistent with the goals of the organization and business plan.

Interface with internal and external constituencies

  • Represents the organization with multiple external regulatory bodies

  • Represent Organization with key employer groups (i.e., USFHP and RCAB) and oversight of the completion of RFPs related to A&G

  • Negotiate resolution of highly escalated or complex situations.

  • Assess, implement, and respond to Regulatory Agency requests for process review and update

  • Oversee the external review process for all products including but not limited to contracting with external review organizations, serving as primary contact for the IRE and overseeing the relationship with consultants

  • Primary representative during departmental audits

  • Responsible for coordinating with partner departments to develop seamless end to end processes across all levels of the organization

  • Primary accountability for ensuring compliance to all relevant requirements

Staff Development

  • The Director must develop and maintain a highly engaged, highly effective and diverse work force

  • Ensure the effective and timely process of performance management. This includes the process of effective coaching/mentoring, promotion of and enablement of training, ongoing feedback, delivery of performance reviews, and the overall process of developing talent within the organization.

  • Monitor and evaluate specific and general performance against standard measures (when appropriate). As needs and opportunities for practical improvements arise, investigate, and recommend methods to achieve goals, including work measurement analysis, retraining or reassignment of personnel.

  • Ensure that staff is educated on corporate and departmental policies, procedures and changes and properly trained in all aspects of reimbursement related functions

  • Evaluate and establish performance and quality standards for department responsibilities in conjunction with company accepted quality standards

  • The Director’s other tasks include:

  • Develop and maintain the administrative budget for the Appeals and Grievances Department

  • Participate in the development of the annual business plan with a continuous focus on reducing administrative costs

  • Serve on high level task forces, committees, and groups formed to develop new initiatives that have impact on reimbursement, to ensure that any new procedures or policies are consistent with overall corporate business objectives and can be implemented cost effectively.

  • Regularly represent the department’s objectives through oral and written presentations to senior management, staff, internal and external customers

  • Other duties and projects as assigned.

Qualifications – what you need to perform the job


  • Required (minimum): Bachelor’s Degree

  • Preferred: Master’s Degree preferred in business, healthcare administration, legal or clinical area.


  • Required (minimum): 10-15 experience in a managed care setting. Five to seven years of management experience. Understanding of operations process, utilization management and associated regulatory and accreditation requirements. Demonstrated success in business process change. Understanding of operations process utilization management and associated regulatory and accreditation requirements.

  • Preferred:

Skill Requirements

  • Requires high degree of initiative, sound judgment and decision-making capabilities

  • Requires strong ability to work as a team member across multiple levels within the organization

  • Regard for confidential data and adherence to corporate compliance policy

  • Requires strong skills at developing teamwork

  • Results orientation – strives to meet business goals

  • Critical and Analytic thinking – must understand cause and effect, internal and external impact of business changes and THP information systems.

  • Comprehensive knowledge of health policy, sufficient to make decisions regarding Plan benefit structures and coverage issues.

  • Influencing other – particularly those outside of direct reporting relationships.

  • Strong communications skills (formal and informal, written and verbal)

  • Coaching and Mentoring – primarily of reports, but also of others

  • Must have commitment to excellence in customer service

  • Considers creative alternatives to traditional/conventional practices and takes risk when appropriate to the situation.

  • Ability to handle multiple demands – must be able to balance multiple priorities

  • Requires skills to successfully manage special contracts

Working Conditions and Additional Requirements (include special requirements, e.g., lifting, travel) :

  • Must be able to work under normal office conditions and work from home as required.

  • Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended durations.

  • May be required to work additional hours beyond standard work schedule.

Confidential Data: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Will be exposed to and required to deal with highly confidential and sensitive material and must always adhere to corporate compliance policy and department guidelines/policies and all applicable laws and regulations.


The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

  • Medical, dental and vision coverage

  • Retirement plans

  • Paid time off

  • Employer-paid life and disability insurance with additional buy-up coverage options

  • Tuition program

  • Well-being benefits

  • Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit

Commitment to Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity

​Point32Health is committed to making diversity, equity, inclusion, accessibility and health equity part of everything we do—from product design to the workforce driving that innovation. Our Diversity, Equity, Inclusion, Accessibility (DEIA) and Health Equity team's strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

At Point32Health, we strive to be a different kind of nonprofit health and well-being company, with a broad range of health plans, and innovative tools that make navigating health and well-being easier, guiding our members at every step of their health care journey to better health outcomes. We are committed to providing high-quality and affordable health care, improving the health and wellness of our members, and creating healthier communities across the country. The Point32Health name is inspired by the 32 points on a compass. It speaks to the critical role we play in guiding and empowering the people we serve to achieve healthier lives. Our employees are hard-working, innovative, and collaborative. They look for opportunities to grow and make a difference, and they help make us strive to be one of the Top Places to work in New England.