Grievance and Appeals Representative I

Solis Health Plans

About The Position

The Grievance and Appeals Representative is responsible for the intake, review, investigation, and resolution of member grievances in a managed care environment. This role ensures all grievances are handled in compliance with regulatory standards established by the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA), as well as internal policies and procedures. The Grievance and Appeals Representative works cross-functionally to ensure timely, accurate, and member-focused resolution of complaints while maintaining regulatory compliance and quality standards.

Requirements

Minimum of 2 years of experience in managed care, healthcare operations, grievances & appeals, or a related function; or equivalent combination of education and experience.
Working knowledge of CMS and NCQA regulations related to grievances and appeals.
Experience investigating and resolving member complaints, appeals, or disputes in a healthcare setting.
Familiarity with claims processing, benefits interpretation, and healthcare delivery systems.
Strong analytical, problem-solving, and investigative skills.
Excellent written and verbal communication skills, with the ability to compose professional, compliant correspondence.

Nice To Haves

Experience in a managed care organization supporting Medicare, Medicaid, Marketplace, or other government-sponsored programs.
Knowledge of grievance classification, quality of care investigations, and regulatory reporting requirements.
Experience working with healthcare providers, medical records, and clinical documentation.
Background in customer service, call center operations, or healthcare compliance.

Responsibilities

Facilitates the end-to-end handling of member grievances, including documentation, investigation, resolution, and closure within established regulatory timelines.
Conducts comprehensive research and investigation of member complaints by reviewing claims, authorizations, medical records, call logs, and correspondence.
Coordinates with internal departments (e.g., Claims, Utilization Management, Provider Relations, Customer Service) and external stakeholders to gather information and ensure accurate resolution.
Interprets and applies CMS and NCQA guidelines, as well as state and federal regulations, to determine appropriate grievance outcomes.
Ensures all grievance cases are processed within required turnaround times and meet quality and compliance standards.
Prepares clear, concise, and compliant written responses to members and/or authorized representatives, explaining the resolution and rationale.
Identifies and escalates potential quality of care issues, access concerns, or systemic trends to appropriate departments.
Maintains accurate and detailed documentation of all grievance activities in accordance with audit and regulatory requirements.
Assists in tracking, trending, and reporting grievance data to identify root causes and support quality improvement initiatives.
Participates in audits, regulatory reviews, and quality assurance activities related to grievance processing.
Communicate with members and providers via written and verbal channels to obtain additional information or provide updates as needed.
Meets departmental productivity, quality, and performance standards.