Appeals and Grievances Specialist

2 нед. назад

USARemote

Handle member and provider appeals and grievances ensuring compliance and resolution within regulatory timelines.

Обязанности

As an Appeals and Grievances Specialist,  you'll  own the end-to-end handling of member and provider appeals and grievances ,  investigating cases, coordinating with internal teams, and delivering clear, well-reasoned resolutions within regulatory timelines.  
This role sits at the intersection of advocacy, compliance, and operations.  You'll  work directly with members and providers who need someone to take their concern seriously, dig into the details, a nd get  them an answer they can trust.  You'll  report to the Director, Quality and Continuous Improvement, and work closely with QA, Claims, Clinical, and Provider Relations to reach fair, well-documented outcomes.  
Intake, triage, and manage a caseload of member and provider appeals and grievances from submission through resolution  
Investigate each case thoroughly ,  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 member and provider communications in Sidecar Health's brand voice  
Track all cases and deadlines to ensure compliance with state and federal turnaround time requirements  
Coordinate with Claims, Clinical, Provider Relations, and Legal teams to gather information and resolve complex cases  
Identify  escalati on risks and loop in leadership or the Grievance Committee when a case requires second-level review  
Spot patterns in appeals and grievances that point to upstream process, system, or communication issues, and flag them to leadership  
Maintain  accurate  records in the case management s ystem  to support audits and regulatory reporting  
Contribute to process improvements, SOP updates, and knowledge base articles for the appeals and  grievance’s  function

Другое

Sidecar Health is redefining health insurance. Our mission is to make excellent healthcare affordable and accessible for everyone. We know that to accomplish this lofty mission, we need driven people who will make things happen.
The passionate people who make up Sidecar Health’s team come from all over, with backgrounds as tech leaders, policy makers, healthcare professionals, and beyond. And they all have one thing in common—the desire to fix a broken system and make it more personalized, affordable, and transparent.
If you want to use your talents to transform healthcare in the United States, come join us!
Bachelor's d egree  require d , 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  need s  
A member-first mindset, balanced with rigorous attention to policy and compliance  
Nice to haves  
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  
Competitive salary ($65,000 - $75,000), bonus opportunity, and equity package  
Comprehensive Medical, Dental, and Vision benefits  
A 401k retirement plan  
Paid vacation and company holidays  
Opportunity to make an impact at a rapidly growing mission-driven company transforming healthcare in the U.S.  
Sidecar Health is an Equal Opportunity employer committed to building a diverse team. We do not discriminate  on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status or disability status.