GRIEVANCE AND APPEALS SPECIALIST

AppleOne Employment Services; Los Angeles (CA); On-site; USD 37,000 - 39,000; Part time

Job summary

AppleOne Employment Services seeks a Grievance and Appeals Specialist to analyze and process non-complex health plan grievances and appeals with a focus on regulatory alignment and clear written communication. You will review cases from members, providers, and third parties within a structured framework.

The position offers cross-functional collaboration, training, and exposure to URAC/NCQA standards, requiring strong writing and analytical abilities in a compliant environment.

Qualifications

• Minimum of 3 years of experience in Commercial Grievances and Appeals.
• Strong business writing skills to communicate determinations clearly.
• Understanding of healthcare claims processes, provider networks, and medical management workflows.
• Ability to follow detailed procedures, regulatory requirements, and internal policies.
• Attention to detail with handling of sensitive healthcare information.

Responsibilities

• Review, analyze, and process non-complex healthcare grievances and appeals from members, providers, regulatory entities, and third parties.
• Research grievance and appeal issues using established guidelines, review tools, claims information, provider network details, and medical records.
• Prepare clear written determination communications in accordance with regulatory, accreditation, and internal policy requirements.
• Route appropriate cases to nursing, medical management, legal, service operations, or other internal teams for additional review.
• Ensure case handling aligns with applicable URAC, NCQA, regulatory, and departmental standards.
• Serve as a liaison between grievance and appeals teams and internal business partners as needed.

Skills

Grievances & Appeals

Business writing

Healthcare claims

Regulatory knowledge

Job description

Job Summary

We are seeking Grievance and Appeals Specialists who enjoy research, documentation, regulatory accuracy, and clear written communication. This role supports the Enterprise Grievance and Appeals function by reviewing, analyzing, and processing non-complex pre-service and post-service grievance and appeal requests. The position offers exposure to multiple health plan products, cross-functional collaboration, structured training, established guidelines, and supportive processes that help team members succeed in a compliance-focused environment.

Key Responsibilities

• Review, analyze, and process non-complex healthcare grievances and appeals from members, providers, regulatory entities, and third parties.
• Research grievance and appeal issues using established guidelines, review tools, claims information, provider network details, and medical records.
• Prepare clear written determination communications in accordance with regulatory, accreditation, and internal policy requirements.
• Route appropriate cases to nursing, medical management, legal, service operations, or other internal teams for additional review.
• Ensure case handling aligns with applicable URAC, NCQA, regulatory, and departmental standards.
• Serve as a liaison between grievance and appeals teams and internal business partners as needed.

Pay, Type, and Location

• Pay rate: $27 to $27.20 per hour.
• Job type: Contract/Temporary.
• Location: Los Angeles, CA. Candidates must reside within 50 miles of Woodland Hills, CA.
• Flexible PST schedule options available after training: 7:30 a.m. to 4:00 p.m., 8:00 a.m. to 4:30 p.m., or 9:00 a.m. to 5:30 p.m.

Required Qualifications and Skills

• High school diploma or equivalent.
• Minimum of 3 years of experience in Commercial Grievances and Appeals.
• Strong business writing skills with the ability to communicate determinations in clear, understandable language.
• Understanding of healthcare claims processes, provider networks, and medical management workflows.
• Strong analytical, problem-solving, interpersonal, and oral communication skills.
• Ability to follow detailed procedures, regulatory requirements, accreditation standards, and internal policies.
• Strong attention to detail and ability to manage sensitive healthcare information accurately and professionally.

Preferred Qualifications

• Experience working in a healthcare insurance, managed care, or health plan environment.
• Familiarity with HMO, PPO, POS, EPO, CDHP, indemnity, or related health plan products.
• Knowledge of URAC and NCQA accreditation requirements.
• Experience using internal healthcare claims, grievance, appeal, or customer service technology platforms.
• Prior experience supporting regulatory, executive, provider, or member grievance cases.

Equal Opportunity Employer / Disabled / Protected Veterans

The Know Your Rights poster is available here: https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf

The pay transparency policy is available here: https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf

For temporary assignments lasting 13 weeks or longer, AppleOne is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required.

We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team.

AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program. https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf

We also consider for employment qualified applicants regardless of criminal histories, consistent with legal requirements, including, if applicable, the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment-qualified applicants with arrest and conviction records, including, if applicable, the San Francisco Fair Chance Ordinance. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.