Appeals and Grievance Specialist

The Appeals & Grievances Specialist III role manages and resolves member complaints, grievances appeals, and some regulatory inquiries to ensure accurate, timely, and compliant outcomes. The role applies full proficiency in administrative, clinical, and regulatory processes to independently handle complex and high-risk cases. Operating with minimal supervision, the Specialist III exercises advanced judgement in case evaluation, prioritization, and resolution. The position contributes to team effectiveness by supporting workflow consistency, providing guidance to peers, and identifying opportunities to improve processes and compliance outcomes. The role plays a key part in maintaining service quality and regulatory adherence across the Appeals & Grievances function. Performs other duties as assigned. 

Key Accountabilities

• Manage & Respond to Complex Member Complaints, Grievances, & Appeals
  • Independently review and evaluate complex or high-risk cases to determine appropriate resolution in accordance with regulatory, contractual, clinical, and policy requirements
  • Ensure appropriate routing and coordination of clinical and non-clinical case components
  • Communicate clear, accurate, and professional determinations to members, providers, and internal stakeholders
  • Ensure all cases meet established standards for quality, accuracy, timeliness, and compliance
  • Maintain thorough, accurate, and audit-ready documentation for all case activity

• Support Escalations, Executive Complaints & Regulatory Inquiries
  • Support the review and coordination of escalated, high-visibility, and executive-level complaints requiring advanced analysis
  • Assist in drafting clear, accurate, and compliant responses to regulatory agencies (e.g., CMS, state regulators) in alignment with established standards
  • Collaborate with cross-functional stakeholders to gather information and support complete and accurate case resolution
  • Track and monitor regulatory timelines to ensure adherence to response requirements and escalate risks as needed

• Apply Advanced Administrative & Regulatory Expertise
  • Interpret complex regulatory requirements, policies, and contractual obligations to guide case handling decisions
  • Identify systemic issues, trends, or process gaps and communicate findings to leadership
  • Recommend and support implementation of process improvements that enhance compliance, quality, and efficiency
  • Ensure documentation practices support audit readiness and regulatory expectations

• Collaborate & Provide Guidance to Team Members
  • Serve as a resource to peers by providing guidance on complex cases, processes, and documentation standards
  • Share insights and trends identified through casework to improve team performance and consistency
  • Partner with internal teams to resolve issues and ensure alignment across workflows
  • Contribute to a collaborative team environment focused on service excellence and compliance

• Exercise Advanced Judgement & Influence Outcomes
  • Apply advanced professional judgment to resolve complex or ambiguous cases within regulatory and organizational guidelines
  • Determine and adjust approaches to case handling based on risk, urgency, and compliance considerations
  • Recommend procedural enhancements and contribute to continuous improvement initiatives
  • Prioritize workload effectively across competing deadlines and regulatory requirements

Required Qualifications

• High school diploma or equivalent
• 3+ in appeals and grievances, healthcare operations, insurance, or related field

Preferred Qualifications

• 3-5+ years of experience in appeals and grievances, healthcare operations, insurance, or related field 

Skills and Abilities

• Outstanding written and verbal communication skills
• Strong problem-solving and analytical abilities to ensure timely and thorough case resolution
• Ability to work effectively with staff at all levels, as well as members and providers
• Demonstrated skill in managing multiple priorities in a fast-paced environment
• Proficiency with Microsoft Word, Excel, and Outlook