Appeals and Grievances Specialist
S
Sidecar HealthHealth Insurance
Location: RemoteFull-TimeMiddle
SalaryCompetitive salary ($65,000 - $75,000), bonus opportunity, and equity package
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Job Details
- Experience
- 3+ years
- Required Skills
- Salesforce
Requirements
- Bachelor's degree in 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, including state DOI requirements, ERISA, and ACA
- Strong analytical skills, comfortable reading claims data, plan documents, and clinical notes
- Excellent written communication skills with the ability to explain complex determinations in plain, empathetic language
- Proven track record of managing a caseload independently and meeting hard deadlines
- Member-first mindset balanced with rigorous attention to policy and compliance
- Experience with Genesys Cloud, Salesforce, or similar case management and CRM platforms preferred
- Familiarity with Medicare Advantage or ACA marketplace appeals processes preferred
- Prior experience in a fast-growing or start-up health insurance environment preferred
Responsibilities
- 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 company policy to reach accurate, well-documented determinations
- Draft clear, compliant resolution letters and communications
- Track cases and deadlines to ensure compliance with state and federal turnaround time requirements
- Coordinate with Claims, Clinical, Provider Relations, and Legal teams to resolve complex cases
- Identify escalation risks and contribute to process improvements, SOP updates, and knowledge base articles
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