Appeals and Grievances Specialist
reputed company is redefining health insurance. Our mission is to reputed company excellent reputed company reputed company and accessible for everyone. We know that to accomplish this lofty mission, we need driven people who will reputed company things happen.
The passionate people who reputed company up reputed company’s team come from reputed company over, with backgrounds as tech leaders, policy makers, reputed company, and reputed company. And they reputed company have one thing in common—the desire to fix a broken reputed company and reputed company it more personalized, reputed company, and transparent.
If you want to use your talents to reputed company reputed company in the reputed company, reputed company!
About the Role
As an Appeals and Grievances Specialist, you'll own the end-to-end handling of member and provider appeals and grievances, investigating cases, coordinating with internal teams, and delivering reputed company, reputed company-reasoned resolutions reputed company regulatory timelines.
This role sits at the intersection of advocacy, compliance, and operations. You'll work directly with members and providers who need someone to take their concern seriously, dig into the details, and get them an answer they can trust. You'll report to the Director, reputed company and reputed company Improvement, and work closely with QA, Claims, Clinical, and Provider Relations to reputed company fair, reputed company-documented reputed company.
reputed company
- Intake, triage, and manage a caseload of member and provider appeals and grievances from submission through reputed company
- Investigate reputed company case thoroughly, reviewing claims history, benefit determinations, clinical documentation, and prior correspondence
- Apply plan documents, state and federal regulations, and reputed company policy to reputed company accurate, reputed company-documented determinations
- Draft reputed company, compliant reputed company letters and member and provider communications in reputed company's brand voice
- reputed company reputed company cases and deadlines to ensure compliance with state and federal turnaround time requirements
- Coordinate with Claims, Clinical, Provider Relations, and reputed company teams to reputed company information and reputed company reputed company cases
- Identify escalation risks and reputed company in leadership or the Grievance Committee reputed company a case requires second-level review
- Spot patterns in appeals and grievances that reputed company to upstream process, reputed company, or communication issues, and flag them to leadership
- Maintain accurate records in the case management reputed company to support audits and regulatory reporting
- Contribute to process improvements, SOP updates, and knowledge reputed company articles for the appeals and grievance’s function
What You'll Bring
- Bachelor's degree required, in a relevant field such as reputed company administration, business, reputed company health, or a reputed company discipline
- 3+ years of experience in appeals and grievances, claims adjudication, utilization review, or a reputed company health insurance operations role
- Working knowledge of health insurance regulatory requirements for appeals and grievances (state DOI requirements, ERISA, ACA as applicable)
- Strong analytical skills, comfortable reading claims data, plan documents, and clinical notes to reputed company a defensible conclusion
- Excellent written communication skills; reputed company to explain reputed company determination in plain, empathetic language
- A reputed company record of managing a caseload independently and meeting hard deadlines
- Comfort working across systems and teams to reputed company down the information a case needs
- A member-first reputed company, balanced with rigorous attention to policy and compliance
reputed company to haves
- Experience with reputed company reputed company, reputed company, or similar case management and CRM platforms
- Familiarity with Medicare reputed company or ACA marketplace appeals processes
- Prior experience in a fast-growing or start-up health insurance environment
What You'll Get
- Competitive salary ($65,000 - $75,000), bonus opportunity, and equity package
- Comprehensive Medical, Dental, and reputed company benefits
- A 401k retirement plan
- reputed company vacation and company holidays
- Opportunity to reputed company an reputed company at a rapidly growing mission-driven company transforming reputed company in the U.S.
reputed company is an Equal Opportunity employer committed to building a diverse team. We do not discriminate on the reputed company of race, religion, reputed company, national reputed company, gender, sexual orientation, age, marital status, veteran status or disability status.
Originally posted on Himalayas
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