Principal Domain Consultant – Healthcare Contact Center & Appeals & Grievances (A&G)
- 📅
- CREQ246138 Requisition #
- 📅
- Feb 10, 2026 Post Date
Principal Domain Consultant – Healthcare Contact Center & Appeals & Grievances (A&G)
Location: United States (Remote/Hybrid)
Travel: Up to 25–40% (client-dependent)
Employment Type: Full-time
Key Responsibilities
1. Contact Center Assessments (Payer Focused)
- Lead end-to-end contact center maturity assessments across:
- Member Services, Provider Services, Pharmacy Services, and Enrollment
- Evaluate:
- Call routing, IVR, omnichannel strategy
- Average Handle Time (AHT), First Call Resolution (FCR), abandonment, ASA
- Workforce management, QA, training, and escalation models
- Identify root causes of member abrasion, repeat calls, and avoidable contacts
- Benchmark against CMS, NCQA, and industry best practices
- Develop future-state operating models, including automation and digital deflection opportunities
2. Appeals & Grievances (A&G) Assessments
- Conduct comprehensive A&G operational and compliance assessments across:
- Intake, classification, investigation, determination, and notification
- Evaluate compliance with:
- CMS regulations (MA, Medicaid, ACA)
- Timeliness standards, notice language, and audit readiness
- Identify gaps in:
- End-to-end workflows
- Case routing, medical necessity reviews, and decision governance
- Vendor oversight and delegation models
- Assess linkages between contact center complaints → grievances → appeals
- Deliver regulator-ready remediation and improvement roadmaps
3. Executive Advisory & Stakeholder Leadership
- Serve as primary domain authority for client leadership (VP–C-suite)
- Facilitate executive workshops, readouts, and decision forums
- Translate regulatory requirements into clear operational actions
- Influence cross-functional leaders (Operations, Compliance, Medical, IT)
4. Transformation Strategy & Roadmap Development
- Define multi-year transformation roadmaps spanning:
- Process simplification
- Technology enablement (CRM, case management, workflow)
- Automation and AI (intelligent routing, summarization, QA augmentation)
- Partner with solution architects and delivery teams to ensure feasible execution
- Support business case development (ROI, cost take-out, experience uplift)
Experience
- 14–18+ years in healthcare payer operations, consulting, or advisory roles
- Deep hands-on experience in:
- Healthcare contact center operations and/or
- Appeals & Grievances (A&G) for MA, Medicaid, or Commercial plans
- Prior experience in:
- Top-tier or boutique healthcare consulting firms OR
- Senior leadership roles within a health plan
Domain Expertise
- Strong command of:
- CMS regulations (MA & Medicaid)
- A&G timeliness, notice, and audit requirements
- Member and provider experience drivers
- Working knowledge of:
- CRM and case management platforms – Pega Blueprint, Pega workflow
- Call center technologies (IVR, WFM, QA, omnichannel tools)
- Familiarity with NCQA, STAR Ratings, and state DOI oversight
Principal Domain Consultant – Healthcare Contact Center & Appeals & Grievances (A&G)
Location: United States (Remote/Hybrid)
Travel: Up to 25–40% (client-dependent)
Employment Type: Full-time
Key Responsibilities
1. Contact Center Assessments (Payer Focused)
- Lead end-to-end contact center maturity assessments across:
- Member Services, Provider Services, Pharmacy Services, and Enrollment
- Evaluate:
- Call routing, IVR, omnichannel strategy
- Average Handle Time (AHT), First Call Resolution (FCR), abandonment, ASA
- Workforce management, QA, training, and escalation models
- Identify root causes of member abrasion, repeat calls, and avoidable contacts
- Benchmark against CMS, NCQA, and industry best practices
- Develop future-state operating models, including automation and digital deflection opportunities
2. Appeals & Grievances (A&G) Assessments
- Conduct comprehensive A&G operational and compliance assessments across:
- Intake, classification, investigation, determination, and notification
- Evaluate compliance with:
- CMS regulations (MA, Medicaid, ACA)
- Timeliness standards, notice language, and audit readiness
- Identify gaps in:
- End-to-end workflows
- Case routing, medical necessity reviews, and decision governance
- Vendor oversight and delegation models
- Assess linkages between contact center complaints → grievances → appeals
- Deliver regulator-ready remediation and improvement roadmaps
3. Executive Advisory & Stakeholder Leadership
- Serve as primary domain authority for client leadership (VP–C-suite)
- Facilitate executive workshops, readouts, and decision forums
- Translate regulatory requirements into clear operational actions
- Influence cross-functional leaders (Operations, Compliance, Medical, IT)
4. Transformation Strategy & Roadmap Development
- Define multi-year transformation roadmaps spanning:
- Process simplification
- Technology enablement (CRM, case management, workflow)
- Automation and AI (intelligent routing, summarization, QA augmentation)
- Partner with solution architects and delivery teams to ensure feasible execution
- Support business case development (ROI, cost take-out, experience uplift)
Experience
- 14–18+ years in healthcare payer operations, consulting, or advisory roles
- Deep hands-on experience in:
- Healthcare contact center operations and/or
- Appeals & Grievances (A&G) for MA, Medicaid, or Commercial plans
- Prior experience in:
- Top-tier or boutique healthcare consulting firms OR
- Senior leadership roles within a health plan
Domain Expertise
- Strong command of:
- CMS regulations (MA & Medicaid)
- A&G timeliness, notice, and audit requirements
- Member and provider experience drivers
- Working knowledge of:
- CRM and case management platforms – Pega Blueprint, Pega workflow
- Call center technologies (IVR, WFM, QA, omnichannel tools)
- Familiarity with NCQA, STAR Ratings, and state DOI oversight