Appeals & Grievances Specialist I

Western Health Advantage•Sacramento, CA

2d•$22 - $25•Hybrid

About The Position

Western Health Advantage is seeking a detail-oriented and highly organized Appeals & Grievances Specialist I to support the accurate, timely, and compliant processing of member appeals and grievances. This role is integral to ensuring regulatory adherence while advocating for members and delivering exceptional service in a fast-paced environment. The Appeals & Grievances Specialist I is responsible for applying comprehensive knowledge of WHA’s practices, policies, benefit guidelines, contractual agreements, and regulatory requirements in the review and processing of appeals and grievances. This position ensures compliance with all applicable regulatory standards and timeframes, including those established by the California Department of Managed Health Care (DMHC), National Committee for Quality Assurance (NCQA) accreditation standards, and HIPAA/PHI privacy regulations. The role requires extensive collaboration with internal departments and external partners, including medical groups, providers, authorized representatives, brokers, and hospital systems.

Requirements

High School Diploma required.
Minimum two (2) years of experience in appeals and grievances within the healthcare industry; HMO experience strongly preferred.
Working knowledge of regulatory requirements related to DMHC, NCQA, and HIPAA/PHI privacy standards.
Intermediate computer proficiency, including Microsoft Word and Excel.
Strong written and verbal communication skills with the ability to draft clear, member-focused correspondence.
Ability to manage multiple cases and priorities in a fast-paced environment while maintaining attention to detail.

Nice To Haves

Experience with HMO claims adjudication, referrals, and authorizations (utilization management) preferred.

Responsibilities

Case Intake & Investigation
Serve as the assigned specialist responsible for intake, research, and investigation of member appeals and grievances.
Represent the member’s interests from initial triage through resolution.
Classify and process appeals and grievances across a broad range of categories, including but not limited to:
Enrollment/disenrollment
Premium billing
Access and care coordination
Medical and pharmacy benefits
Prior authorizations
Claims processing and reimbursement
Deductibles and out-of-pocket maximums
Utilization management
Quality of care and compliance matters
Regulatory Compliance & Risk Identification
Ensure cases meet all regulatory guidelines and mandated timeframes.
Identify case urgency, expedited requests, and potential quality-of-care concerns.
Recognize potential violations including PHI/HIPAA breaches, fraud, contract concerns, and statute of limitations issues.
Notify members of expedited request determinations and their right to contact the DMHC when applicable.
Coordination & Communication
Conduct outreach to members and authorized representatives to obtain additional information as needed.
Collaborate with internal departments and contracted entities to gather pertinent documentation and medical records.
Evaluate information received to ensure sufficiency for Plan determination.
Maintain ongoing follow-up to secure timely and complete responses.
Documentation & Member Communication
Maintain accurate, thorough documentation of case activity, communications, medical records, and committee decisions.
Customize acknowledgement letters summarizing member concerns.
Assist in drafting resolution letters aligned with benefit guidelines and/or medical necessity determinations, including member education.
Operational Support & Continuous Improvement
Identify and report trends or recurring issues during intake.
Participate in process improvement initiatives and training enhancements.
Support team members and assist the A&G Coordinator with monitoring incoming and outgoing communications (email, mail, fax).
Perform additional duties and special projects as assigned.