Appeals and Grievances Specialist

Remote Wisconsin•Menasha, WI

3d•Hybrid

About The Position

Network Health is seeking an Appeals and Grievance Specialist I to review member appeals and grievances, investigate and summarize findings, compile supporting documentation, and prepare summaries of determinations. The role supports the organization’s commitment to providing members with high-quality service through the appeals process and works collaboratively across internal departments and with providers. Candidates must reside in Wisconsin. The position is eligible to be performed from a home office with reliable internet access, with occasional travel to the corporate office in Menasha or Brookfield required, including on the first day. The role is 1.0 FTE, 40 hours per week, Monday through Friday, 8 a.m. to 5 p.m.

Requirements

At least two years of experience working for a health insurance carrier or in a similar environment.
High school diploma or equivalent.
Excellent communication skills and the ability to interpret insurance plans and regulations.
Strong Microsoft Word and Excel skills and the ability to research regulations.

Nice To Haves

Experience in appeals and grievances, customer service, claims, utilization management, or compliance.
Experience working with state and federal regulations, such as Medicare, ERISA, and Office of the Commissioner of Insurance regulations.
Associate degree.

Responsibilities

Review assigned appeals and grievances and determine the supporting documentation needed to address each issue.
Compile supporting documentation for the appeal process.
Resolve discrepancies in information with internal departments or providers as needed.
Communicate with members about the status of submitted appeals and conduct outreach to obtain missing information.
Educate members about the appeal or grievance process to help mitigate future issues or concerns.
Investigate and summarize findings, present cases, and obtain resolutions from designated Network Health sources for assigned benefit-related cases within legally required timeframes and applicable regulations.
Document investigation and resolution activity in the Appeals and Grievance database, including the dates and times of required verbal and written notifications.
Collaborate with the legal department on hearing requests before an Administrative Law Judge (ALJ).
Prepare and submit required documentation for hearings.
Represent Network Health by phone or in person, as necessary, to provide testimony regarding the company’s position on benefit determinations.
Prepare letters or written summaries for members, providers, and third parties explaining benefit determinations and their rationale in accordance with member benefit documents and applicable regulations.
Demonstrate behavior aligned with Network Health’s philosophy, mission, values, and vision.
Perform other duties and responsibilities as assigned.