Grievance & Appeals Specialist - Remote

Overview

We are seeking a detail-oriented Grievance & Appeals Specialist to join our team on a temporary, remote basis. In this role, you’ll manage member and provider complaints, appeals, and grievances, ensuring compliance with NCQA, CMS, and state regulations. Your work will help maintain strong relationships and accurate benefit determinations while supporting regulatory standards and internal quality.

In Short

• Review and classify member and provider grievance and appeal requests
• Determine benefits, eligibility, and prior activity related to the issue
• Send written acknowledgments and conduct outreach calls to clarify complaints
• Investigate thoroughly using internal and external resources
• Collaborate with internal departments and external entities for case resolution
• Prepare detailed case summaries for medical and administrative review
• Track and monitor cases to ensure timely resolution within regulatory deadlines
• Write clear, accurate responses that fully address the issue
• Maintain documentation and reporting per internal standards
• Identify process improvement opportunities and share recommendations

Requirements

• Associate degree in a related field (Bachelor’s preferred)
• 3+ years of relevant professional experience
• Experience in healthcare, managed care, or compliance required
• Strong communication and writing skills
• Proven ability to manage sensitive information with accuracy and professionalism
• Proficiency in Microsoft Office (especially Word and Excel)
• Strong analytical and organizational skills

Benefits

• Payday Fridays
• Dental, Vision, STD and/or LTD
• Voluntary Life & AD&D, Accident, Critical Illness, Hospital Indemnity
• Health Advocate EAP, and Health Equity Commuter Benefits
• ZayZoon, and 401k