Appeals and Grievances Specialist

Job Summary

Owning the end-to-end handling of member and provider appeals and grievances, the full-time Appeals and Grievances Specialist will investigate cases, coordinate with internal teams, and deliver clear resolutions in a remote work environment.

Key responsibilities

• Intake, triage, and manage a caseload of member and provider appeals and grievances from submission through resolution
• Investigate each case thoroughly, reviewing claims history, benefit determinations, and clinical documentation
• Draft clear, compliant resolution letters and communications while tracking all cases to ensure compliance with regulatory timelines

Required qualifications

• Bachelor's degree in healthcare administration, business, public health, or a related discipline
• 3+ years of experience in appeals and grievances, claims adjudication, or a related health insurance operations role
• Working knowledge of health insurance regulatory requirements for appeals and grievances
• Strong analytical skills with the ability to read claims data and clinical notes
• Proven track record of managing a caseload independently and meeting deadlines