Claims Specialist

SNI Companies; California (MO); On-site; USD 42,000 - 65,000; Full time

Job summary

SNI Companies is seeking a detail-oriented Grievance & Appeals Customer Service Representative to join the Enterprise Grievance & Appeals Department. This role will review, research, document, and resolve non-complex grievances and appeals while delivering professional, timely customer service.

The ideal candidate brings strong customer service, written communication, research, analytical, and problem-solving skills, with the ability to manage sensitive healthcare-related concerns in a

Qualifications

• High School Diploma or GED required.
• Previous experience in customer service, healthcare, health insurance, claims, grievances and appeals, or a related administrative environment preferred.
• Strong business writing and written communication skills with the ability to explain complex information clearly and professionally.
• Strong research, analytical, problem-solving, organizational, and interpersonal skills.
• Ability to work with confidential members, provider, claims, and medical information.
• MUST LIVE IN CALIFORNIA.

Responsibilities

• Review, research, and process pre-service and post-service grievances and appeals submitted by members, providers, regulatory agencies, and third parties.
• Investigate issues involving claims, benefits, provider networks, quality of service, quality of care, and clinical/non-clinical services across HMO, PPO, POS, EPO, CDHP, and indemnity products.
• Provide professional customer service and issue resolution, ensuring members and provider concerns are thoroughly researched, documented, and addressed within required timeframes.
• Analyze claims history, account information, medical records, correspondence, and supporting documentation to determine appropriate next steps.
• Prepare clear, accurate, and professional written grievance and appeal determination letters using customer-friendly language.
• Utilize established guidelines and review tools to approve eligible non-complex cases or elevate appropriate cases to nursing, medical, legal, or management teams for further review.
• Maintain accurate and complete case documentation while adhering to strict regulatory accreditation, privacy, and departmental requirements, including URAC and NCQA standards.
• Serve as a liaison between Grievances & Appeals, Medical Management, Claims, Legal, Service Operations, and other internal departments to facilitate timely case resolution.

Skills

Customer service

Healthcare experience

Written communication

Research & analysis

Data confidentiality

Interpersonal skills

Education

High School Diploma or GED

Job description

Grievance & Appeals Customer Service Representative

We are seeking a detail-oriented Grievance & Appeals Customer Service Representative to join the Enterprise Grievance & Appeals Department. This position is responsible for reviewing, researching, documenting, and resolving non-complex member and provider grievances and appeals while delivering professional, accurate, and timely customer service.

The ideal candidate has strong customer service, written communication, research, analytical,and problem-solving skills with the ability to manage sensitive healthcare-related concerns in a fast-paced, highly regulated environment.

Key Responsibilities

• Review, research, and process pre-service and post-service grievances and appeals submitted by members, providers, regulatory agencies, and third parties.
• Investigate issues involving claims, benefits, provider networks, quality of service, quality of care, and clinical/non-clinical services across HMO, PPO, POS, EPO, CDHP, and indemnity products.
• Provide professional customer service and issue resolution, ensuring members and provider concerns are thoroughly researched, documented, and addressed within required timeframes.
• Analyze claims history, account information, medical records, correspondence, and supporting documentation to determine appropriate next steps.
• Prepare clear, accurate, and professional written grievance and appeal determinationletters using customer-friendly language.
• Utilize established guidelines and review tools to approve eligible non-complex cases or elevate appropriate cases to nursing, medical, legal, or managementteams for further review.
• Maintain accurate and complete case documentation while adhering to strict regulatory accreditation, privacy, and departmental requirements, , including applicable URAC and NCQA standards.
• Serve as a liaison between Grievances & Appeals, Medical Management, Claims, Legal,Service Operations, and other internal departments to facilitate timely case resolution.

Qualifications

• High School Diploma or GED required.
• Previous experience in customer service, healthcare, health insurance, claims, grievances andappeals, or a related administrative environment preferred.
• Strongbusiness writing and written communication skills with the ability to explain complex information clearly and professionally.
• Strong research, analytical, problem-solving, organizational, and interpersonal skills.
• Ability to work with confidential members, provider, claims, and medical information.
• MUST LIVE IN CALIFORNIA

Ideal Candidate

• The successful candidate will be a customer-focused, analytical, and highly organized professional who can investigate concerns, communicate effectively with members and providers, manage sensitive information, and produce accurate written responses while meeting strict quality and compliance standards.