Grievance & Appeals Resolution Specialist

Applicants must reside in California. Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values. Job Summary The Appeals & Grievances Resolution Specialist supports the intake, investigation, and resolution of member grievances, appeals, provider disputes, and complaints in accordance with CMS regulations, NCQA standards, and applicable state and contractual requirements. This role independently manages assigned cases within established guidelines, applies sound analytical judgment to resolve non‑clinical matters, collaborates with clinical and operational partners, and ensures timely, accurate, and compliant case resolution. The specialist is accountable for meeting CMS turnaround time requirements, maintaining audit‑ready documentation, supporting CMS Complaints Tracking Module (CTM) activities, and contributing to quality improvement and Star Ratings performance through effective trend identification and member‑centered communication. The specialist may also assist the Member Services department with overflow calls and outbound campaigns as business needs require. Essential Functions & Job Responsibilities Intake, investigate, document, and resolve member grievances, appeals, and provider disputes in compliance with CMS, NCQA, state, and contractual requirements. Ensure cases are processed within required turnaround times and accurately tracked through resolution. Apply sound, fact‑based decision‑making to resolve non‑clinical complaints and appeals. Communicate with members and providers to obtain additional information, explain decisions, and provide clear written and verbal case outcomes. Support intake, investigation, and resolution of CMS Complaints Tracking Module (CTM) cases, ensuring timely, accurate, and compliant responses. Prepare appeal summaries, determination letters, and supporting documentation for internal review, CMS universes, audits, and oversight entities. Coordinate with Medical Management, Claims, Provider Relations, Compliance, and other departments to facilitate timely case resolution. Maintain accurate, complete, and compliant documentation in case tracking systems. Identify and analyze trends and root causes in grievances, appeals, and complaints, and report findings to leadership to support quality improvement initiatives and reduce repeat issues. Maintain audit‑ready case files and support CMS audit and universe submission activities, including data validation, case review, and response to regulatory requests. Perform quality audits and monitoring activities; report findings and recommend corrective actions. Assist with development and maintenance of desk‑level procedures, job aids, and training materials. Support HEDIS‑related activities as assigned, including data entry, provider outreach, and claims research. Assist Member Services with overflow calls and outbound campaigns during high‑volume periods, as needed. Prepare reports and summaries for internal committees, compliance meetings, and leadership review. Represent the organization professionally and compassionately when interacting with members, providers, and internal partners. Qualifications Required: 2+ years of experience in Medicare Advantage Grievances & Appeals operations. Working knowledge of CMS regulations governing appeals, grievances, and CTM. Experience with case tracking systems and regulatory documentation requirements. Strong analytical, problem‑solving, and decision‑making skills. Excellent written and verbal communication skills. Ability to manage multiple cases and priorities in a fast‑paced environment. Intermediate proficiency in Microsoft Word, Excel, and PowerPoint. Ability to type at least 40 WPM. Preferred: Knowledge of medical and claims coding (CPT, HCPCS, ICD‑10, DRG, Revenue Codes). Experience supporting CMS audits, universes, or regulatory submissions. Bilingual in Korean, Vietnamese, or Mandarin. Wage Range $26.00 to $32.00 per hour. Physical & Working Environment Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation: Must be able to travel when needed or required. Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note‑taking). Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs. Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly. Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business. Clever Care Health Plan is a proud Equal Employment Opportunity and affirmative action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status, or any other status protected by law. A background check is required. Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency. #J-18808-Ljbffr Clever Care Health Plan