Specialist, Admin Complaints, Grievances & Appeals

Oscar Health•Atlanta, GA

4d•$41,731 - $60,858•Remote

About The Position

The CGA Liaison is responsible for the comprehensive management and resolution of complex administrative member or provider grievances and appeals. You will serve as a subject matter expert on non-clinical case resolution, focusing on sensitive member issues such as claims concerns, access barriers, benefits concerns and complex service inquiries. You will drive the resolution process to meet regulatory standards set by the health plan's governing bodies, while promoting member satisfaction and retention. You will report into our CGA Team Lead.

Requirements

1+ years of professional experience in a regulated industry, such as healthcare, insurance, or finance.
1+ years of experience independently managing a demanding caseload with multi-step workflows, from initial intake through investigation, resolution, and final documentation.
1+ years of experience with directly managing escalated customer, member or provider cases.
1+ years of experience drafting and issuing formal written communication to member and providers.
1+ years of experience working in a structured, workflow-driven, environment.

Nice To Haves

Bachelor's degree.
Experience in health care administration.
Involvement in departmental or process improvement or quality programs.
Bilingual proficiency in English and Spanish.

Responsibilities

Follow established workflows to log initial assessment on complex or escalated administrative grievances from members or providers.
Conduct, multi-faceted investigations by gathering and analyzing internal data, call logs, and correspondence.
Use workflows to reconstruct complex event timelines involving prior authorizations, claims processing, and system-based adjudication edits to determine the cause of member or provider issues.
Collaborate with internal departments, such as Member Services, Eligibility & Benefits, and Claims, to obtain necessary information for complete case resolution.
Based on investigative findings, determine a resolution strategy that is both fair and compliant with company and regulatory guidelines, using established workflows.
Escalate the issue to leadership for further guidance on resolution strategy.
Draft clear, accurate, complete resolution letters, including all required regulatory elements.
Maintain meticulous and comprehensive case files in the case management system to provide a clear and complete audit trail for each case.
Manage case timelines to ensure strict adherence to all federal and state mandated deadlines.
Compliance with all applicable laws and regulations.
Other responsibilities as assigned.