Appeals & Claims Operations Administrator

Appeals & Claims Operations Administrator

Healthcare Legal Solutions is seeking two experienced Appeals & Claims Operations Administrators to oversee and coordinate our end-to-end claims appeals workflow. These Administrators will be responsible for developing, implementing, and administering the operational framework for eligibility grievances and appeals, ensuring that case work performed by the team is timely, accurate, and fully compliant with applicable regulations. Rather than directly handling individual cases, these roles will focus on supervising staff workloads, monitoring quality and productivity, refining processes, and keeping all appeal activities on track against internal and client deadlines.

The Appeals & Claims Operations Administrators will have oversight of the appeals and grievances processes across multiple product lines and venues, including internal reviews, informal appeals/reconsiderations, and external or administrative hearings. They will help operationalize regulations, client policies, and internal standards; track appeal volumes and outcomes; identify and implement process improvements; and prepare required operational and performance reports. These roles will supervise the work associated with marketplace/Exchange eligibility appeals, navigator and producer appeals, qualified health plan appeals, and employer and employee eligibility appeals for small-group programs, as applicable to client engagements.

Key Responsibilities

• Lead and supervise day-to-day operations of the appeals and grievances workflow, ensuring cases are assigned, tracked, and completed within required timeframes.
• Oversee staff who conduct clinical, legal, and administrative reviews of appeals, providing direction, feedback, and coaching to maintain consistency and quality.
• Monitor queues, aging, and turnaround times; proactively resolve bottlenecks and escalate issues that could impact service-level agreements.
• Implement and maintain standardized procedures, templates, and work instructions in alignment with federal and state regulations, client policies, and internal quality standards.
• Collaborate with internal leadership and client contacts to clarify expectations, refine processes, and address operational issues.
• Develop, review, and distribute regular reports on volumes, outcomes, timeliness, and quality metrics for appeals and grievances.
• Support onboarding and ongoing training of team members on workflows, documentation standards, and regulatory or policy updates.
• Participate in audits and quality reviews; identify root causes of errors and lead corrective-action plans.

Qualifications

• Bachelor's degree preferred; an Associate degree with strong relevant experience will be considered.
• Prior experience with health plans, TPAs, or healthcare legal/consulting organizations, specifically in Appeals & Grievances, Claims Operations, or Quality/Compliance.
• Proven experience supervising or coordinating teams and workflows (formal people-management experience strongly preferred).
• Familiarity with Medicaid, CMS, and/or marketplace/Exchange regulations is preferred.
• Strong communication, organizational, and time-management skills, with the ability to manage multiple priorities and stakeholders.
• Comfort working in a fast-paced, metrics-driven environment and learning new systems and processes quickly.