Appeals and Grievances Specialist
$65,000–$75,000 year
RemoteUnited States
Job Summary
Intake, triage, and manage a caseload of member and provider appeals and grievances from submission through resolution. Investigate each case thoroughly by 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 communications in the brand voice while tracking all cases and deadlines to ensure regulatory turnaround time requirements are met. Coordinate with Claims, Clinical, Provider Relations, and Legal teams to gather information and resolve complex cases, identifying escalation risks and looping in leadership when second-level review is needed. Spot patterns in appeals to flag upstream process or system issues and contribute to SOP updates and knowledge base articles. Maintain accurate records in the case management system to support audits and regulatory reporting.
Required Qualifications
- 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
Desired Qualifications
- Experience with Genesys Cloud, Salesforce, or similar case management and CRM platforms
- Familiarity with Medicare Advantage or ACA marketplace appeals processes
- Prior experience in a fast-growing or start-up health insurance environment
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