Appeals and Grievances Specialist

6 hours, 4 minutes ago
Full-time
Mid Level
Customer and Technical Support
Sidecar Health

Sidecar Health

Sidecar Health is revolutionizing the health insurance industry by offering transparent and affordable health insurance for individuals, with the freedom to choose any doctor. Their modern approach eliminates networks, referrals, and games, providing u...

Insurance
51-250
Founded 2018
$163M raised

Description

  • Intake, triage, and manage a caseload of member and provider appeals and grievances from submission through resolution.
  • Investigate cases by reviewing claims history, benefit determinations, clinical documentation, and prior correspondence.
  • Apply plan documents, state and federal regulations, and company policy to reach accurate determinations.
  • Draft clear, compliant resolution letters and member and provider communications.
  • Track cases and deadlines to meet state and federal turnaround time requirements.
  • Coordinate with Claims, Clinical, Provider Relations, and Legal teams to gather information and resolve complex cases.
  • Identify escalation risks and involve leadership or the Grievance Committee when second-level review is needed.
  • Spot patterns in appeals and grievances that indicate process, system, or communication issues and flag them to leadership.
  • Maintain accurate case records in the case management system to support audits and regulatory reporting.
  • Contribute to process improvements, SOP updates, and knowledge base articles for the appeals and grievances function.

Requirements

  • Bachelor's degree required in healthcare administration, business, public health, or a related field.
  • 3+ years of experience in appeals and grievances, claims adjudication, utilization review, or a related health insurance operations role.
  • Working knowledge of appeals and grievances regulatory requirements, including state DOI requirements, ERISA, and ACA as applicable.
  • Strong analytical skills with the ability to read claims data, plan documents, and clinical notes to form defensible conclusions.
  • Excellent written communication skills with the ability to explain complex determinations in plain, empathetic language.
  • Experience managing a caseload independently and meeting hard deadlines.
  • Comfort working across systems and teams to gather the information a case needs.
  • A 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 startup health insurance environment (preferred).

Benefits

  • Competitive salary of $65,000-$75,000.
  • Bonus opportunity and equity package.
  • Comprehensive medical, dental, and vision benefits.
  • 401(k) retirement plan.
  • Paid vacation and company holidays.
  • Opportunity to work at a mission-driven company transforming healthcare in the U.S.

Interested in this position?

Apply directly on the company website

Apply Now

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