Appeals and Grievances Specialist

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 clear, well-reasoned resolutions within 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, Quality and Continuous Improvement, and work closely with QA, Claims, Clinical, and Provider Relations to reach fair, well-documented outcomes.

Responsibilities

• Intake, triage, and manage a caseload of member and provider appeals and grievances from submission through resolution
• Investigate each case thoroughly, reviewing claims history, benefit determinations, clinical documentation, and prior correspondence
• Apply plan documents, state and federal regulations, and Sidecar Health policy to reach accurate, well-documented determinations
• Draft clear, compliant resolution letters and member and provider communications in Sidecar Health's brand voice
• Track all cases and deadlines to ensure compliance with state and federal turnaround time requirements
• Coordinate with Claims, Clinical, Provider Relations, and Legal teams to gather information and resolve complex cases
• Identify escalation risks and loop in leadership or the Grievance Committee when a case requires second-level review
• Spot patterns in appeals and grievances that point to upstream process, system, or communication issues, and flag them to leadership
• Maintain accurate records in the case management system to support audits and regulatory reporting
• Contribute to process improvements, SOP updates, and knowledge base articles for the appeals and grievance’s function

Requirements

• Bachelor's degree required, in a relevant field such as healthcare administration, business, public health, or a related discipline
• 3+ years of experience in appeals and grievances, claims adjudication, utilization review, or a related 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 form a defensible conclusion
• Excellent written communication skills; able to explain complex determination in plain, empathetic language
• A track record of managing a caseload independently and meeting hard deadlines
• Comfort working across systems and teams to track down the information a case needs
• A member-first mindset, balanced with rigorous attention to policy and compliance

Skills

• Experience with Genesys Cloud, Salesforce, or similar case management and CRM platforms (nice to have)
• Familiarity with Medicare Advantage or ACA marketplace appeals processes (nice to have)
• Prior experience in a fast-growing or start-up health insurance environment (nice to have)

Benefits

• Competitive salary ($65,000 - $75,000), bonus opportunity, and equity package
• Comprehensive Medical, Dental, and Vision benefits
• A 401k retirement plan
• Paid vacation and company holidays
• Opportunity to make an impact at a rapidly growing mission-driven company transforming healthcare in the U.S.