Appeals, Complaints and Grievances Specialist

We're building a world of health around every individual , shaping a more connected, convenient and compassionate health experience.

Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products. You will ensure timely, customer-focused responses to appeals, complaints and grievances, identifying trends and emerging issues, and recommending solutions.

Key Responsibilities:

• Research incoming electronic appeals, complaints and grievances to identify if they're appropriate for your unit.
• Investigate and resolve appeals, complaints and grievances in a customer-focused manner.
• Coordinate responses from multiple business units and communicate effectively with members and providers.
• Analyze data to identify trends and emerging issues, and provide recommendations for improvement.
• Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues.

Requirements:

• Experience in reading or researching benefit language.
• 1-2 years of experience in claim platforms, products, benefits, patient management, product or contract drafting, compliance and regulatory analysis, special investigations, provider relations, customer service or audit experience.
• Strong analytical skills, attention to detail, and excellent verbal and written communication skills.
• Computer literacy in Microsoft Office, including Excel and Word.

Preferred Qualifications:

• Experience in research and analysis of claim processing.

Education:

• Some college preferred.
• High School or GED equivalent.

Benefits:

• Comprehensive benefits package, including medical, dental, and vision coverage, paid time off, retirement savings options, and wellness programs.