Appeals & Grievance Specialist

Western Health Advantage (WHA) is a mission-driven health plan dedicated to building healthier communities through exceptional service and compliance.

About the role

Support members by managing appeals and grievances while ensuring compliance with state and federal regulations, accreditation standards, and internal policies. Work closely with members, providers, medical groups, and internal departments to investigate concerns, coordinate resolutions, and deliver exceptional service throughout the appeals process.

Responsibilities

• Manage the intake, investigation, and resolution of member appeals and grievances while ensuring regulatory compliance and required turnaround times
• Research and evaluate issues related to benefits, claims, authorizations, enrollment, billing, quality of care, utilization management, and other health plan services
• Determine case urgency, identify expedited requests, and recognize potential compliance, privacy, fraud, or quality concerns
• Collaborate with internal departments, providers, hospitals, and medical groups to gather information and support case resolution
• Maintain accurate case documentation, correspondence, and member communications
• Prepare customized acknowledgment and resolution letters that clearly explain determinations and member rights
• Identify trends and participate in process improvement initiatives to enhance member experience and operational efficiency
• Provide support to the Appeals & Grievances team, including assistance with department communications and special projects

Requirements

• High school diploma required
• Minimum of 2 years of experience in appeals and grievances or a similar healthcare role, preferably within an HMO environment
• Experience with HMO claims adjudication, referrals, and utilization management is preferred
• Strong written and verbal communication, organizational, and problem-solving skills
• Proficiency with Microsoft Word, Excel, and other business applications
• Ability to manage multiple priorities while maintaining accuracy and meeting strict regulatory deadlines

Pay

$22.00 – $27.00 per hour

Schedule

Hybrid (Sacramento, CA)