Director Grievance & Appeals

Grievance And Appeals Director

Blue Cross of Idaho is seeking a strategic and operational leader to oversee the Grievance and Appeals department. This role ensures timely, accurate, and compliant resolution of member and provider complaints, appeals, and grievances across all lines of business. The Director will lead a high-performing team, drive operational excellence, and ensure adherence to federal, state, and accreditation standards, including CMS and NCQA.

This role is located in Meridian, Idaho, reporting to the VP, Business Operations.

To Be Considered For This Opportunity You Have :

Experience : Minimum 10 years in health insurance or healthcare operations, with at least 5 years in a leadership role overseeing grievance and appeals, claims, or customer service.

Education : Bachelor's degree in Business, Nursing, Health Administration, or related field; or equivalent work experience (Two years' relevant work experience is equivalent to one-year college)

Knowledge of :

• CMS regulations and Medicare Advantage complaint / appeal protocols.
• QHP and ASO contract interpretation.
• NCQA and URAC accreditation standards.
• State insurance regulations (e.g., Idaho DOI).
• Data analysis and reporting tools for operational decision-making.
• STARS performance metrics and their impact on Medicare Advantage plans.

We'd also love it if you had :

Key Responsibilities

As of the date of this posting, a good faith estimate of the current pay range is $132,000 to $198,000. The position is eligible for an annual incentive bonus (variable depending on company and employee performance). The pay range for this position takes into account a wide range of factors including, but not limited to, specific competencies, relevant education, qualifications, certifications, relevant experience, skills, seniority, performance, travel requirements, internal equity, business or organizational needs, and alignment with market data. At Blue Cross of Idaho, it is not typical for an individual to be hired at or near the top range for the position. Compensation decisions are dependent on factors and circumstances at the time of offer.

We offer a robust package of benefits including paid time off, paid holidays, community service and self-care days, medical / dental / vision / pharmacy insurance, 401(k) matching and non-contributory plan, life insurance, short and long term disability, education reimbursement, employee assistance plan (EAP), adoption assistance program and paid family leave program. We will adhere to all relevant state and local laws concerning employee leave benefits, in line with our plans and policies.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skill and / or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.