Lead the complaint resolution function, overseeing a team of resolution specialists
Ensure resolution processes are consistent, compliant with HIPAA, CMS, TDI, and internal policy standards, and continuously improving
Serve as the primary cross-functional liaison between the contact center, Legal, Compliance, Quality Assurance, and Operations
Act as the final escalation point for the most complex and sensitive member issues
Direct and supervise team research and analysis of all incoming member and provider complaints to determine root causes and appropriate corrective actions
Develop, implement, and continuously refine resolution methodologies and SOPs for complex member issues
Maintain integrity of the complaint tracking system; ensure all complaint details, investigation steps, resolutions, and follow-up activities are documented
Ensure all complaint-handling procedures adhere to internal policies and applicable regulations
Design and manage proactive member and stakeholder follow-up processes to confirm resolution satisfaction and mitigate issue recurrence
Generate and formally present comprehensive reports on complaint trends, resolution cycle times, and compliance metrics to senior leadership
Develop and oversee the contact center QA program, including call monitoring, transaction review, scoring calibration, and SOP maintenance
Coach, develop, and performance-manage resolution team members; drive process improvement using Lean, Six Sigma, or similar methodologies

3+ years in healthcare contact center operations with a focus on escalations, grievances, or appeals
3+ years in a leadership role with direct reports
Thorough knowledge of health insurance operations: claims, enrollment/eligibility, billing, prior authorization, and provider networks
Expert understanding of HIPAA, CMS, TDI, and state/federal managed care compliance standards
Demonstrated experience with both member and provider services escalation processes
Ability to interpret EOBs, plan policy language, and contractual agreements to resolve member disputes
Strong team leadership, coaching, and performance management skills
Exceptional written and verbal communication skills; able to manage executive-level and high-stakes member communications
Proficiency in complaint tracking/CRM systems and reporting tools
Bachelor's degree preferred; equivalent work experience considered
Experience in a payvider, ACO, or value-based care environment preferred
Lean, Six Sigma, or process improvement methodology certification preferred
Familiarity with HEDIS, Star Ratings, and quality performance metrics preferred
Bilingual in English/Spanish preferred
Experience with Athena or similar EHR platforms preferred
Prior experience in a startup or high-growth healthcare organization preferred.

Supervisor, Escalation

Key skills