Appeals and Grievances Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Take full responsibility for the comprehensive management of member and provider appeals and grievances.

• Receive, assess, and oversee a caseload of member and provider appeals and grievances from initial submission to final resolution.

• Conduct investigations by examining claims history, benefit determinations, clinical documentation, and previous correspondence.

• Utilize plan documents, state and federal regulations, and Sidecar Health policy to make accurate and well-documented decisions.

• Compose clear and compliant resolution letters as well as communications for members and providers.

• Monitor cases and deadlines to ensure adherence to state and federal turnaround time requirements.

• Collaborate with Claims, Clinical, Provider Relations, and Legal teams to address complex cases.

• Recognize escalation risks and engage leadership or the Grievance Committee when a second-level review is needed.

• Detect patterns that reveal upstream process, system, or communication issues and report them to leadership.

• Ensure accurate records in the case management system for audits and regulatory reporting purposes.

• Participate in process enhancements, updates to standard operating procedures (SOPs), and the creation of knowledge base articles.

⛳️ Requirements

• A bachelor's degree is required in healthcare administration, business, public health, or a related field.

• A minimum of 3 years of experience in appeals and grievances, claims adjudication, utilization review, or a similar role within health insurance operations.

• Familiarity with health insurance regulatory requirements related to appeals and grievances, including state Department of Insurance (DOI) requirements, ERISA, and ACA as applicable.

• Strong analytical capabilities and the ability to interpret claims data, plan documents, and clinical notes to draw defensible conclusions.

• Exceptional written communication skills with the ability to convey complex determinations in straightforward, empathetic language.

• Proven ability to independently manage a caseload while meeting strict deadlines.

• Comfortable navigating across various systems and teams to gather case information.

• A member-first approach with a strong focus on policy and compliance.

• Experience with Genesys Cloud, Salesforce, or similar case management and CRM systems is a plus.

• Knowledge of Medicare Advantage or ACA marketplace appeals processes is a plus.

• Previous experience in a rapidly growing or start-up health insurance environment is a plus.

🏝️ Benefits

• Competitive salary ranging from $65,000 to $75,000.

• Opportunity for bonuses.

• Equity package offered.

• Comprehensive benefits including Medical, Dental, and Vision coverage.

• A 401k retirement plan available.

• Paid vacation time and company holidays.

• Chance to make a significant impact at a rapidly expanding, mission-driven company that is transforming healthcare in the U.S.