Grievance & Appeals Specialist
About The Position
Our Grievance & Appeals Specialist is responsible for reviewing and resolving member and provider grievances, complaints, appeals, and provider claim disputes across the Health Plan division, including Commercial and Medicare product lines. This role ensures all cases are handled accurately, timely, and in full compliance with contractual and regulatory requirements. This position serves as a key point of coordination between members, providers, and internal partners, working closely with Health Plan Operations, Network Solutions, Pharmacy, Utilization Management, Legal, and other teams to support thorough case review and resolution. Key responsibilities include reviewing incoming submissions, prioritizing urgent matters, conducting detailed case investigations, maintaining accurate documentation and tracking systems, and composing clear, compliant decision communications. The role also supports compliance audits, reporting on performance metrics, and actively managing case inventory to meet established timelines. Success in this role requires strong analytical thinking, attention to detail, the ability to manage high-volume workloads, and a commitment to delivering a high-quality, compliant member experience. This Specialist ensures adherence to standards set by Centers for Medicare and Medicaid Services (CMS), Executive Office of the Health and Human Services (EOHHS), Office of the Health Insurance Commissioner (OCI), Utilization Review Accreditation Commission (URAC), and other applicable guidelines.
Requirements
- High school diploma or equivalent.
- 3 or more years of experience in healthcare customer service or healthcare grievance and appeals.
- Strong knowledge and understanding of grievance and appeals processes, insurance regulations, and claims adjudication.
- Solid knowledge and understanding of federal and state regulations governing health insurance complaints, grievances, appeals, and member rights.
- Strong written and verbal communication skills with the ability to effectively explain complex information to members, authorized representatives, and providers.
- Strong organizational skills, attention to detail, problem-solving skills and ability to meet strict deadlines.
- Familiarity with health plan operational areas such as customer service, provider service, claims processing, utilization management, pharmacy and dental.
Nice To Haves
- Associate's degree or higher in healthcare administration, business, or related field.
- Hands-on experience processing and resolving grievance and appeals in a health plan environment.
- Working knowledge of regulatory requirements (e.g., Centers for Medicare and Medicaid Services (CMS), Office of the Health Insurance Commissioner (OCI), and Utilization Review Accreditation Commission (URAC)) and how they apply to day-to-day work.
- Experience using claims or case management systems to track, document, and manage cases.
- Proven ability to manage a high-volume caseload, prioritize urgent items, and consistently meet turnaround time requirements.
- Experience communicating directly with members, providers, or representatives to explain decisions, gather information, and resolve issues.
Responsibilities
- Reviewing and resolving member and provider grievances, complaints, appeals, and provider claim disputes.
- Ensuring all cases are handled accurately, timely, and in full compliance with contractual and regulatory requirements.
- Serving as a key point of coordination between members, providers, and internal partners.
- Working closely with Health Plan Operations, Network Solutions, Pharmacy, Utilization Management, Legal, and other teams to support thorough case review and resolution.
- Reviewing incoming submissions and prioritizing urgent matters.
- Conducting detailed case investigations.
- Maintaining accurate documentation and tracking systems.
- Composing clear, compliant decision communications.
- Supporting compliance audits.
- Reporting on performance metrics.
- Actively managing case inventory to meet established timelines.
- Investigating issues, coordinating resolutions, and ensuring timely follow-up with thorough documentation.
- Compiling detailed case files and supporting materials for review committees.
- Preparing clear, professional written communications that meet regulatory requirements.
- Coordinating external reviews, including preparing submissions, meeting deadlines, and tracking progress.
- Interpreting and explaining benefits, policies, and procedures to members, representatives, and providers.
- Communicating effectively to gather information, provide updates, and support decision-making.
- Staying organized and monitoring multiple cases at once, ensuring progress and visibility for stakeholders.
- Identifying trends and partnering across teams to improve processes and the member experience.
- Supporting leadership with policies, compliance reporting, and training initiatives.
Benefits
- Remote and hybrid work options available
- Performance bonus and/or merit increase opportunities
- 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
- Competitive paid time off
- Health insurance, dental insurance, and telehealth services start DAY 1
- Professional and Leadership Development Programs
Stand Out From the Crowd
Upload your resume and get instant feedback on how well it matches this job.
What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
