Grievance & Appeals (G&A) Specialist

Job Overview The Grievance & Appeals (G&A) Specialist is responsible for the strategic leadership, regulatory compliance, and operational performance of the health plan’s grievance and appeals functions. This role ensures timely, accurate, and compliant handling of all member and provider grievances and appeals while driving continuous process improvement and reducing regulatory risk. In this role, you will be responsible for managing and resolving member grievances and appeals related to healthcare services, ensuring compliance with regulatory standards, and providing exceptional support to members and providers. Regulatory & Compliance Oversight • Ensure full compliance with CMS, state DOI, ERISA, and URAC requirements • Maintain audit readiness (CMS, OID, internal audits) • Oversee policies, procedures, and regulatory updates • Lead corrective action plans (CAPs) and PDSAs when needed • Serve as primary escalation point for high-risk or sensitive cases Operational Leadership • Oversee intake, case management, clinical review coordination, and decision-making processes • Ensure adherence to timeliness standards (Part C, Part D, Commercial) • Monitor overturn rates, quality scores, and decision accuracy • Manage vendor relationships (if applicable) • Align staffing model to volume and regulatory complexity 3. Quality & Performance Management • Establish KPIs: • Timeliness • Accuracy • Overturn rates • Root cause trends • Implement quality audit program • Identify systemic issues impacting member experience or claim adjudication • Partner with Claims, UM, Customer Service, and Configuration to reduce appeal drivers Duties • Review and analyze member grievances and appeals related to insurance claims, medical billing, and healthcare services • Conduct thorough investigations into medical documentation, medical records, and clinical information to support appeal decisions • Verify insurance coverage, Medicare, Medicaid, and other program eligibility through insurance verification processes • Maintain organized filing systems for medical records, appeal documentation, and correspondence in compliance with confidentiality regulations • Collaborate with healthcare providers, insurance carriers, and internal teams to gather necessary information for case resolution • Prepare detailed reports on appeal outcomes, including recommendations based on medical documentation and legal considerations such as workers’ compensation law • Ensure all activities adhere to regulatory guidelines and organizational policies while providing transparent communication to members Experience • 7–10+ years health plan experience • 4+ years of management experience required • Deep CMS Medicare Advantage knowledge • Experience leading audit responses • Strong understanding of clinical review workflows Job Types: Full-time, Contract Pay: $50.00 - $65.00 per hour Expected hours: 40 per week Work Location: Remote Apply tot his job Apply To this Job