Grievance and Appeals Specialist

About the role

A Healthcare Plan in San Bernardino is in need of a Grievance and Appeals Specialist with strong health plan industry experience to join their team. The Grievance and Appeals Specialist is responsible for reviewing, investigating, and resolving member and provider grievances and appeals in compliance with regulatory requirements and internal policies. The Grievance and Appeals Specialist candidate will have hands-on experience working within EZ-CAP and a solid understanding of health plan operations.

Responsibilities

• Review, research, and process member and provider grievances and appeals accurately and within required turnaround times
• Use EZ-CAP to document, track, and manage case activity
• Analyze case details, benefits, claims, authorizations, and supporting documentation to determine appropriate resolutions
• Ensure all grievances and appeals are handled in accordance with health plan policies, CMS, DMHC, and other applicable regulatory guidelines
• Communicate with internal departments, providers, and members regarding case status and resolution
• Prepare written correspondence for grievance and appeal determinations
• Maintain complete, accurate, and audit-ready documentation
• Identify trends or recurring issues and escalate as needed

Requirements

• At least 3 years of experience handling medical claims, grievances, appeals, or related health plan casework.
• Practical experience working within EZ- for case documentation, tracking, and resolution management.
• Strong understanding of medical claims processing, medical billing, and insurance claim administration.
• Knowledge of health plan operations, including HMO and PPO environments, benefit structures, and authorization review.
• Ability to investigate complex issues, interpret supporting documentation, and make accurate case determinations.
• Experience preparing clear written correspondence for members, providers, or internal stakeholders.
• Familiarity with regulatory and policy requirements governing grievance and appeal handling in a managed care setting.

Benefits

Benefits are available to contract/temporary professionals, including medical, vision, dental, and life and disability insurance. Hired contract/temporary professionals are also eligible to enroll in our company 401(k) plan.