Appeals and Grievances Specialist

About the role

The Appeals & Grievances Specialist plays a vital role in ensuring fair, timely, and compliant resolution of member and provider disputes. This position helps maintain trust, improve customer satisfaction, and uphold organizational integrity by balancing empathy, objectivity, and regulatory compliance when resolving complex issues.

Responsibilities

• Receive, review, and process grievances and appeals from members, patients, providers, or clients regarding claims, coverage, benefits, and service concerns.
• Conduct thorough investigations to gather relevant information, assess the validity of complaints, and determine appropriate resolutions.
• Manage pre-service authorizations, concurrent and retrospective medical necessity reviews, and complex provider claim disputes.
• Ensure timely and accurate processing of appeals and grievances in accordance with established policies and regulatory requirements.
• Maintain complete and accurate documentation of all complaints, investigations, decisions, and resolutions within organizational systems.
• Ensure all grievance and appeal activities comply with applicable federal, state, and organizational regulations, including CMS, DHCS, DMHC, NCQA, and other governing standards.
• Prepare reports and summaries for leadership and regulatory agencies as required, identifying trends, root causes, and potential areas of concern.
• Participate in internal audits, external reviews, inter-rater reliability assessments, and compliance oversight activities.
• Monitor performance metrics and case turnaround times to ensure compliance with regulatory and contractual requirements.
• Serve as a primary point of contact for members, patients, providers, and internal departments throughout the grievance and appeals process.
• Communicate decisions clearly and professionally while ensuring confidentiality and regulatory compliance.
• Provide guidance on appeal rights, procedures, and requirements to stakeholders.
• Collaborate with clinical teams, operations, customer service, and other departments to resolve issues and improve member and provider experiences.
• Advocate for fair and equitable resolution of disputes while maintaining objectivity and professionalism.
• Analyze grievance and appeal trends to identify recurring issues, operational gaps, and opportunities for process improvement.
• Develop recommendations and corrective action plans to reduce future disputes and improve service outcomes.
• Maintain the integrity, accuracy, and completeness of grievance and appeals databases.
• Support quality improvement initiatives through data analysis, reporting, and stakeholder feedback.

Qualifications

• Bachelor's degree or equivalent experience in related field
• 3+ years of work experience beyond degree
• Preferred qualifications: 3+ years of experience in appeals and grievances, healthcare operations, insurance or related field.

Skills and Abilities

• Outstanding written and verbal communication skills
• Strong problem-solving and analytical abilities to ensure timely and thorough case resolution
• Ability to work effectively with staff at all levels, as well as members and providers
• Demonstrated skill in managing multiple priorities in a fast-paced environment
• Proficiency with Microsoft Word, Excel, and Outlook