Grievance Specialist

Job Summary

Managing and resolving member-initiated grievances, the full-time remote Grievance Specialist will advocate for Healthfirst members by conducting thorough investigations and ensuring compliant resolutions across various product lines, including Medicare and Medicaid.

Key Responsibilities

• Independently manage a caseload of grievances through the full case lifecycle, from acknowledgment to resolution
• Conduct detailed research by collaborating with internal departments to identify root causes and recommend resolutions
• Draft and issue clear and compliant acknowledgment and resolution letters to members

Required Qualifications

• HS Diploma or GED from an accredited institution
• Understanding of utilization management processes and their impact on member access to care
• Proficient in Microsoft Office Suite, including Excel and case tracking systems
• 2+ years of experience in managed care, member services, or healthcare grievances resolution
• Familiarity with applicable state and federal regulatory requirements, such as CMS regulations