Appeals & Grievances Specialist

About Our Client:The organization is a nonprofit health plan serving over one million members across multiple states including Minnesota, Nebraska, Wisconsin, and Missouri. It addresses the challenge of delivering personalized healthcare by partnering closely with providers to ensure members receive coordinated and quality care. The organization's reach and commitment position it to impact a broad community through connected care services. About the Opportunity:The APPEALS & GRIEVANCES SPECIALIST role is responsible for managing and resolving complex member complaints, grievances, appeals, and certain regulatory inquiries. This position ensures accurate, timely, and compliant outcomes by applying advanced administrative, clinical, and regulatory knowledge. The role supports team effectiveness through guidance and process improvement, playing a critical part in maintaining service quality and regulatory compliance. Responsibilities:Review and evaluate complex or high-risk cases independently to determine appropriate resolutions.Coordinate clinical and non-clinical case components effectively.Communicate clear and professional determinations to members, providers, and stakeholders.Ensure cases meet standards for quality, accuracy, timeliness, and compliance.Maintain thorough and audit-ready documentation.Support escalated and executive-level complaints and regulatory inquiries.Assist in drafting responses to regulatory agencies in alignment with standards.Collaborate across teams to gather information and ensure case resolution.Track regulatory timelines and escalate risks as needed.Interpret complex regulatory requirements and contractual obligations.Identify systemic issues and recommend process improvements.Serve as a resource and provide guidance to peers on complex cases and documentation.Share insights to improve team performance and consistency.Apply advanced judgment to resolve complex cases within guidelines.Prioritize workload effectively across competing deadlines. Requirements:High School Diploma or equivalent.Minimum 3 years of experience in healthcare operations, insurance, or related field.At least 1 year of direct experience on an appeals and grievances team within a health plan.Ability to work Central time zone core hours with flexible start time.Primary residence in a state where the organization is registered as an employer. Preferred Qualifications:Experience with Commercial and/or Individual, Family and Business plans.Medicare and/or Medicaid plan experience.Experience with State Fair Hearings.Familiarity with CMS guidelines and regulatory agencies. Pay Range and Compensation Package:Salary grade ranges from $45,900 to $78,600, with typical hiring between $45,900 and $68,775.Annual salary placement depends on experience, education, certifications, and other factors.Eligibility for incentive plan compensation in addition to base salary. Benefits & Perks:Competitive medical, dental, and vision insurance.Paid time off and holidays.Paid volunteer time off.401(k) contributions.Caregiver services. Equal Opportunity Statement: Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin. Note:RemoteHunter is a recruitment partner of this role. Please note that all employment decisions, including candidate assessment, interviews, hiring, compensation, and employment terms, are made exclusively by the hiring employer.