CTM Appeals & Grievances Lead — Compliance & Impact

Alignment Healthcare USA, LLC in; Orange (CA); Remote; USD 48,000 - 73,000; Full time

Job summary

Alignment Health is seeking a detail-oriented Member Services specialist to monitor the CTM portal, acknowledge grievances, and coordinate CMS-compliant resolutions for Medicare Advantage plans.

The role is remote and requires weekend availability, with responsibilities including investigations, drafting CMS-facing correspondence, and preparing monthly and quarterly reports while maintaining CMS deadlines and internal policies. Experience with CTM cases and bilingual English/Spanish preferred.

Qualifications

• Experience: at least one year in Member Services or similar.
• 2+ years with Medicare Advantage healthcare plans.
• Preferred: direct CTM case experience with Medicare Advantage.

Responsibilities

• Monitors the CTM portal daily for new cases.
• Acknowledges receipt of CTM grievances and appeals.
• Gathers information to determine resolutions following CMS policies.
• Completes outreach to members and providers per CMS guidelines.
• Investigates CTM cases, grievances, and appeals thoroughly and timely.
• Documents actions to resolve cases in CMS-aligned timeframes.
• Produces monthly and quarterly reports; supports audits and compliance.

Skills

Strong communication

CMS knowledge

Attention to detail

Time management

Bilingual English/Spanish

Documentation skills

Education

High school diploma or GED

Associate degree (A.A.)

Job description

Alignment Health is seeking a detail-oriented Member Services specialist to monitor the CTM portal, acknowledge grievances, and coordinate CMS-compliant resolutions for Medicare Advantage plans.

The role is remote and requires weekend availability, with responsibilities including investigations, drafting CMS-facing correspondence, and preparing monthly and quarterly reports while maintaining CMS deadlines and internal policies. Experience with CTM cases and bilingual English/Spanish preferred.