Appeals Specialist

Appeals Specialist

Department: Appeals & Grievances

Classification: Non-Exempt

Schedule: 8:30AM - 5:00PM (Hybrid)

Position Overview

We are seeking a detail-oriented Appeals & Grievances Specialist I to support the timely review, investigation, and resolution of member appeals, complaints, and grievance cases. This role serves as a key advocate for members by ensuring concerns are thoroughly researched, properly documented, and resolved in accordance with regulatory requirements, health plan policies, and contractual obligations.

Responsibilities

• Review, investigate, and process member appeals and grievances from intake through resolution.
• Serve as the primary point of contact for assigned cases, ensuring member concerns are addressed promptly and professionally.
• Gather, analyze, and evaluate information necessary to support case determinations.
• Identify case urgency and determine whether expedited review criteria are met.
• Triage cases and route requests to the appropriate departments or clinical teams for further review when necessary.
• Ensure all regulatory timelines and service standards are met.
• Conduct outreach to members, authorized representatives, providers, and other stakeholders to obtain additional information and clarification.
• Communicate case status updates and decisions in a clear, professional manner.
• Draft customized acknowledgement and resolution letters that accurately summarize case details and outcomes.
• Educate members regarding benefit coverage, appeal rights, and grievance processes.

• Investigate a wide range of member concerns, including: Enrollment and disenrollment issues, Access to care and care coordination, Prior authorizations and referrals, etc.
• Identify potential quality concerns, HIPAA/privacy issues, fraud concerns, and other compliance-related matters for escalation.
• Maintain accurate and thorough case documentation, including correspondence, medical records, outreach efforts, investigations, and determinations.
• Ensure compliance with healthcare regulations, accreditation standards, privacy requirements, and organizational policies.

Qualifications

• High School Diploma or equivalent.
• Minimum of two years of experience in appeals and grievances, member advocacy, claims, customer service, or a related healthcare role.
• Knowledge of healthcare operations, health plan benefits, and member services processes.
• Strong written and verbal communication skills.
• Intermediate proficiency with Microsoft Office, including Word and Excel.
• Excellent organizational skills with strong attention to detail.
• Ability to manage multiple priorities and meet strict deadlines.
• Demonstrated ability to maintain confidentiality and handle sensitive information.
• Experience within an HMO, managed care, health plan, or healthcare insurance environment.
• Knowledge of claims processing, referrals, authorizations, or utilization management.
• Familiarity with healthcare regulatory requirements and accreditation standards.

Benefit offerings include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits and 401K plan. Our program provides employees the flexibility to choose the type of coverage that meets their individual needs. Available paid leave may include Paid Sick Leave, where required by law; any other paid leave required by Federal, State, or local law; and Holiday pay upon meeting eligibility criteria.

Pay Details: $25.00 to $26.00 per hour

Equal Opportunity Employer/Veterans/Disabled Military connected talent encouraged to apply

Ref: US_EN_27_814362_3132437