Customer Advocacy Specialist

Antidote Health is a tech-driven health insurance company on a mission to make healthcare easier, accessible, and more affordable. We’re rethinking how healthcare works—using technology to remove the friction, complexity, and delays that define the traditional system. Instead of navigating paperwork, long waits, and disconnected experiences, we’re building a simpler, more connected way for people to get care. Our platform combines health coverage, virtual care, and a modern member experience into one seamless system designed to help people actually use their benefits. We offer Affordable Care Act (ACA) health plans in Arizona, Ohio, Georgia, and Texas, and we’re growing quickly. We’re building a company focused on solving real problems—with real impact on people’s lives. Position Overview The Customer Advocacy Specialist investigates and coordinates high-sensitivity complaints, appeals, grievances, executive escalations, agency inquiries, and regulatory matters. This role requires strong writing, investigative judgment, deadline management, compliance awareness, and the ability to coordinate accurate, neutral, and defensible responses. Antidote Health's mission is to redefine healthcare by providing affordable, high-quality, accessible care and insurance products. The Customer Success organization supports that mission by making healthcare easier to understand, easier to access, and easier to navigate for members, brokers, patients, providers, and internal partners. Investigate regulatory complaints, appeals, grievances, BBB inquiries, executive escalations, CMS or HICS matters, state DOI matters, and other high-sensitivity cases. Collect and analyze case records, call notes, emails, claims information, billing history, eligibility records, plan documents, provider information, and internal findings. Draft clear, factual, neutral, and compliant response summaries for leadership review, agency submission, or customer communication. Track regulatory deadlines, required documentation, extensions, case status, owner assignments, and follow-up commitments. Partner with Compliance, Legal, Billing, Finance, Claims, Enrollment, Network, Clinical Operations, Product, Tier 1, and Tier 2 to obtain accurate information. Maintain complaint logs, case files, investigation notes, and supporting documentation in a complete and audit-ready manner. Identify root cause themes and recommend corrective actions that reduce repeat complaints and regulatory exposure. Handle sensitive customer matters professionally while avoiding speculation, unsupported conclusions, or admissions outside approved guidance. Support NCQA, CMS, state DOI, internal audit, and quality reporting requirements as assigned. Meet timeliness, quality, documentation, and regulatory requirements. Hybrid or remote work arrangement based on business need, role requirements, and company policy. Qualifications Required 3 or more years of healthcare, health insurance, customer operations, appeals, grievances, regulatory operations, compliance support, or escalations experience. Strong written communication, investigation, documentation, and analytical skills. Ability to manage deadlines and multiple high-priority cases simultaneously. Working knowledge of health insurance operations, complaints, member services, claims, billing, eligibility, and privacy requirements. Ability to remain neutral, factual, and professional in sensitive or high-risk matters. High school diplima of GED required Preferred Appeals and grievances, CMS, HICS, state DOI, BBB, regulatory complaint, compliance, legal operations, or audit support experience. Experience with ACA marketplace plans, NCQA categories, complaint logs, and corrective action tracking. Salesforce, case management, document management, and regulatory tracking experience. Experience drafting formal business, regulatory, or executive response letters. Associate or bachelor's degree in healthcare administration, business, communications, legal studies, public health, or related field preferred. Core Competencies Ownership and accountability: Works issues to resolution rather than transferring responsibility unnecessarily. Member and customer advocacy: Seeks to understand the customer goal, the barrier, the accountable owner, and the fastest compliant path to resolution. Clear communication: Translates benefits, eligibility, deductibles, claims, referrals, prior authorization, premiums, and other healthcare concepts into plain language. Critical thinking: Identifies root causes, asks investigative questions, and recognizes when an issue does not align with expected process or system behavior. Calm authority: Communicates findings with accuracy, confidence, and professionalism while avoiding speculation. Emotional intelligence and de-escalation: Steadies difficult interactions and maintains professionalism under pressure. System fluency: Navigates CRM, claims, eligibility, benefits, provider lookup, payment, scheduling, knowledge base, and case management tools efficiently. Compliance mindset: Maintains HIPAA, privacy, CMS, ACA, state DOI, and internal policy requirements. Documentation discipline: Records clear, complete, and audit-ready notes that support continuity and accountability. Adaptability and resilience: Succeeds in a fast-paced, evolving health plan environment. Compensation and Benefits Base salary range: $26-30/hour (commensurate with experience and location) Comprehensive benefits package, including medical, dental, and vision 401(k) Paid vacation, sick time, and company holidays Company Standards and Expectations Employment is at-will, meaning either the employee or the company may terminate employment at any time, with or without cause, in accordance with applicable law. Employees are expected to adhere to all company policies, including confidentiality, data protection, and code of conduct. Responsibilities may evolve based on business needs, and flexibility is expected. Compliance with all applicable federal, state, and local laws and regulations is required. Equal Opportunity Statement Antidote Health is an equal opportunity employer and makes employment decisions without regard to race, color, religion, sex, national origin, age, disability, veteran status, or any other protected status under applicable law. #J-18808-Ljbffr Antidote Health Group