Appeals and Grievances Representative, Intermediate

Your Work   In this role, you will: Answer telephone inquiries regarding member appeals. Respond to appeals and grievances and member reconsiderations. Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process. Interpret and explain health plan benefits, policies, procedures and functions to members and providers.  Administer ongoing grievance tracking, trending, and reporting for assigned grievances. Review incoming appeals and grievances and determine which area to assign case to or reroute if the issue does not meet appeal or grievance criteria.  Work in a collaborative manner with your team to meet compliance timeframes. Manage your time independently to ensure that all job duties are completed in a timely manner. Your Work   In this role, you will: Answer telephone inquiries regarding member appeals. Respond to appeals and grievances and member reconsiderations. Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process. Interpret and explain health plan benefits, policies, procedures and functions to members and providers.  Administer ongoing grievance tracking, trending, and reporting for assigned grievances. Review incoming appeals and grievances and determine which area to assign case to or reroute if the issue does not meet appeal or grievance criteria.  Work in a collaborative manner with your team to meet compliance timeframes. Manage your time independently to ensure that all job duties are completed in a timely manner. Your Knowledge and Experience   Requires a high school diploma or GED Requires at least 2 years in health insurance operations such as I&B, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination Commercial/IFP health plan knowledge preferred Requires knowledge of Microsoft Systems such as Power Point, Excel, and Word

Created: 2025-07-06