Appeals & Grievances Specialist II
About The Position
Western Health Advantage is seeking a detail-oriented and experienced Appeals & Grievances Specialist II to support the timely and compliant processing of member appeals and grievances. In this fast-paced role, you will conduct comprehensive case reviews, ensure adherence to DMHC and NCQA regulatory standards, and collaborate with internal and external stakeholders to facilitate fair and accurate determinations. This position is ideal for a healthcare professional who thrives in structured, regulatory environments, enjoys investigative case work, and is committed to protecting member rights while ensuring compliance and quality outcomes.
Requirements
- High School Diploma or equivalent
- Minimum of 3 years of experience in a similar role with progressively increasing responsibilities
- Strong written and verbal communication skills
- Ability to read, write, speak, and understand the primary language(s) used in the workplace
Nice To Haves
- Experience with claims adjudication, referrals, and authorizations
- Previous experience working in the healthcare industry, particularly within an HMO environment
- Knowledge of medical terminology and the ability to clearly explain it to others
- Intermediate computer skills, including Microsoft Word and Excel, email, databases, and spreadsheets
Responsibilities
- Reviewing cases escalated from prior levels to ensure accurate classification, complete documentation, and appropriate categorization
- Providing accurate and timely written and verbal communication to members, providers, medical groups, brokers, delegated entities, and internal departments
- Confirming that requests have been routed to the appropriate entities and following up on missing responses
- Requesting and evaluating relevant documentation, medical records, and supporting information to ensure sufficient data for Plan determinations
- Maintaining thorough and accurate documentation of all outreach, communications, and case activities
- Identifying urgent matters or potential quality issues and promptly triaging cases to clinical staff or next-level support
- Preparing and organizing comprehensive case files, including medical records and written summaries for review
- Writing non-clinical case summaries and supporting administrative benefit/coverage dispute reviews
- Assisting with resolution letters based on benefit guidelines and/or medical necessity determinations, including member education
- Collaborating closely with A&G nurses to prepare cases for Appeal Review Meetings
- Identifying escalated matters and effectively communicating next steps
- Reporting emerging trends or recurring issues identified during case reviews
- Participating in process improvement initiatives and development of desktop guidelines
- Supporting team members with increased responsibilities and assisting in training new staff when requested
- Maintaining external contact lists and contracted counterparts for appeals and grievances
- Performing additional duties and special projects as assigned
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
