Appeals & Grievances Specialist I

Appeals & Grievances Specialist I

"Purpose that inspires. Impact that improves lives. Join us in building healthier communities." 
Western Health Advantage

Western Health Advantage (WHA) is seeking a detail-oriented and customer-focused Appeals & Grievances Specialist I to join our team. In this fast-paced role, you will support members by managing appeals and grievances while ensuring compliance with state and federal regulations, accreditation standards, and internal policies. You will work closely with members, providers, medical groups, and internal departments to investigate concerns, coordinate resolutions, and deliver exceptional service throughout the appeals process.

What You'll Do

• Manage the intake, investigation, and resolution of member appeals and grievances while ensuring regulatory compliance and required turnaround times.
• Research and evaluate issues related to benefits, claims, authorizations, enrollment, billing, quality of care, utilization management, and other health plan services.
• Determine case urgency, identify expedited requests, and recognize potential compliance, privacy, fraud, or quality concerns.
• Collaborate with internal departments, providers, hospitals, and medical groups to gather information and support case resolution.
• Maintain accurate case documentation, correspondence, and member communications.
• Prepare customized acknowledgment and resolution letters that clearly explain determinations and member rights.
• Identify trends and participate in process improvement initiatives to enhance member experience and operational efficiency.
• Provide support to the Appeals & Grievances team, including assistance with department communications and special projects.

What We're Looking For

• High school diploma required.
• Minimum of 2 years of experience in appeals and grievances or a similar healthcare role, preferably within an HMO environment.
• Experience with HMO claims adjudication, referrals, and utilization management is preferred.
• Strong written and verbal communication, organizational, and problem-solving skills.
• Proficiency with Microsoft Word, Excel, and other business applications.
• Ability to manage multiple priorities while maintaining accuracy and meeting strict regulatory deadlines.

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law. (EOE)

Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you—and excellent customer service for our members.