Appeals and Grievances Specialist

Network Health; Menasha (WI); Remote; USD 52,000 - 70,000; Full time

Job summary

Network Health is seeking an Appeals and Grievance Specialist I to join our Wisconsin team. The role reviews member appeals, investigates findings, and prepares determinations in a compliant, collaborative environment.

The position requires at least two years in a health insurance setting, with strong communication and regulatory interpretation skills. Remote 1.0 FTE, with occasional travel to offices in Menasha or Brookfield.

Qualifications

• Two years of experience in health insurance or related field.
• Experience with Medicare, ERISA or related regulations preferred.
• Ability to interpret plans and regulations.

Responsibilities

• Fully reviews appeals and grievances to determine needed documentation.
• Compile and reconcile documentation with internal teams and providers.
• Communicate appeals status to members and gather missing info.
• Investigate, summarize findings, and obtain resolution within regulatory timeframes.
• Document investigations and notifications in the database.

Skills

Communication skills

Regulatory research

Customer service

Education

High School diploma or equivalent

Associates degree preferred

Tools

Microsoft Word

Microsoft Excel

Job description

Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking an Appeals and Grievance Specialist I to join our team.

This individual will review appeals and grievances filed by members, investigate and summarize findings regarding the appeals, compile supporting documentation, and prepare summaries of the determination in a collaborative, innovative environment. We strive to provide world-class service to our members through the appeals process.

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required). Travel to the corporate office in Menasha or Brookfield will be required occasionally for the position, including on first day.

Hours: 1.0 FTE, 40 hours per week, 8am-5pm Monday through Friday

Check out our 2025 Community Report to learn a little more about the difference our employees make in the communities we live and work in. As an employee, you will have the opportunity to work hard and have fun while getting paid to volunteer in your local neighborhood. You too, can be part of the team and making a difference.

Job Responsibilities:

• Fully reviews all appeals and grievances assigned, to determine appropriate supporting documentation needed to address the issue being appealed.
• Compile supporting documentation for appeal process. Resolve any discrepancies in information with internal departments or providers as necessary.
• Communicate with members regarding status of appeals that have been submitted. Perform necessary outreach as appropriate to gather any missing information needed to continue with their appeal or grievance. Educate members on the appeal or grievance process to mitigate future potential issues or concerns which may arise.
• Investigate, summarize findings, present cases, and obtain resolution from designated sources at Network Health for all assigned benefit-related cases within legally required timeframes and in accordance with all applicable regulations.
• Accurately and consistently document all aspects of the investigation and resolution process in the Appeals and Grievance database, as well as documenting time and date verbal and written notifications were provided to members or others as required by applicable regulations and audit standards.
• Collaborate with the legal department regarding hearing requests before an Administrative Law Judge (ALJ). Prepare and submit required documentation for hearing. Represent Network Health as necessary, via phone or in person to provide testimony related to company's position on the benefit determination.
• Prepare letters or written summaries to members, providers and third parties outlining Network Health's benefit determination, clearly articulating the rationale in conformance with the member benefit document and applicable state and/or federal regulations
• Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health
• Other duties and responsibilities as assigned.

Job Requirements:

• A minimum of two years of experience working for a health insurance carrier or similar environment is required, preferably in the fields of appeals and grievance, customer service, claims, utilization management or compliance.
• Prior experience working with state and federal regulations such as Medicare, ERISA, Office of Commissioner of Insurance regulations, and similar regulations is preferred.
• Excellent communication skills along with the ability to interpret insurance plans and regulations
• Strong Word and Excel skills, along with the ability to research regulations
• High School diploma or equivalent required, Associates degree preferred

Network Health is an Equal Opportunity Employer.

Equal Opportunity Employer

This employer is required to notify all applicants of their rights pursuant to federal employment laws.

For further information, please review the Know Your Rights notice from the Department of Labor.