Location: Lee’s Summit, MO (Hybrid; remote considered)
Reports to: Chief Operating Officer
Team Size: 25–35 (post‑reorganization)
Position Type: Interim with temp‑to‑hire option
Pay: Depends on experience, negotiable
The Director, Appeals Operations & Enrollment provides unified leadership across Appeals (including OPM 2nd‑level) and Enrollment functions.
The Director serves as a senior operational leader, representing OPM‑facing reviews, driving vendor accountability, and shaping the reorganized Appeals + Enrollment operating model.
Set strategic direction for Appeals and Enrollment, including planning, performance management, and resource allocation.
Lead the operational stabilization plan aligned with the company's commitments to OPM.
Establish metrics, quality standards, and operating rhythms that support audit‑defensible decision‑making.
Identify operational gaps, risks, and capability needs across both functions.
Drive continuous improvement and cross‑functional alignment.
Lead all levels of appeals: member, provider, and OPM 2nd‑level federal appeals.
Ensure decision quality, documentation rigor, and communication standards that withstand OPM scrutiny.
Personally review a representative sample of OPM 2nd‑level decisions and escalate quality concerns.
Redesign escalation pathways with clear SLAs, thresholds, and triggers.
Ensure compliance with FEHB, PSHB, and all applicable federal/state regulations.
Lead enrollment operations across FEHB, PSHB, and additional product lines.
Maintain quality standards for onboarding, eligibility verification, and member communications.
Oversee Open Season readiness and execution.
Partner with the TPA on enrollment processing, error remediation, and member impact resolution.
Serve as lead governance owner for Appeals and Enrollment with the third‑party administrator.
Identify vendor performance gaps and lead remediation; escalate to COO/CLO when needed.
Coordinate with Independent Quality Assurance (“audit‑the‑auditor”) on findings and remediation tracking.
Act as senior operational point of contact for OPM communications and reviews.
Author and review OPM‑facing materials related to Appeals and Enrollment quality.
Represent company in OPM operational reviews.
Partner with the Chief Legal Officer on regulatory exchanges and sensitive communications.
Lead and develop a reorganized team of 25–35 across Appeals and Enrollment.
Establish operating rhythms (staff meetings, 1:1s, performance reviews).
Hire, retain, coach, and transition team members as needed.
Build a culture of regulatory discipline, operational excellence, and member‑centric service.
Coach teams on regulator‑grade communication and documentation.
Partner with Operational Oversight, Independent QA, and BPO Oversight on shared priorities.
Collaborate with Legal on regulatory and contractual matters.
Work with Technology Services on systems supporting Appeals and Enrollment.
Engage SME consultants (Claims, Dental, Reporting & Analytics) on shared methodologies.
Partner with People & Culture on talent strategy and organizational design.
Bachelor’s degree required.
Master’s in business, healthcare administration, public administration, or related field preferred.
10+ years progressive leadership in healthcare payer operations.
5+ years managing teams of 20+ FTE.
Direct leadership of appeals operations, including federal program appeals (FEHB, MA, Medicaid).
Experience leading large‑scale enrollment operations.
Proven ability to produce regulator‑grade documentation and withstand external audit.
Experience managing TPA/BPO vendors from the payer side.
Strong communication skills for executive and regulator audiences.
Direct OPM 2nd‑level FEHB appeals experience.
FEHB or PSHB carrier operations experience.
Experience with UMR, UHG, Optum, or similar TPA governance.
Experience leading operational reorganizations or large‑scale change.
Experience in organizations with $5B+ annual revenue.
Strategic Operational Leadership — ability to prioritize, lead through ambiguity, and drive stabilization.
Regulatory Acumen — deep understanding of federal program requirements and regulator expectations.
People Leadership — ability to develop, retain, and hold teams accountable.
Vendor Governance Discipline — structured oversight, escalation, and contract‑based accountability.
Quality & Risk Orientation — disciplined approach to quality, RCA, and risk identification.
Communication & Influence — strong executive and regulator‑facing communication.
Operational Integration — ability to unify cross‑functional responses and coordinate across teams.
Hybrid work environment based in Lee’s Summit, MO
Up to 15% travel (vendor sites, OPM offices, conferences).
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