Grievance & Appeals Case Specialist

TEKsystems; Fairfield (CA); Hybrid; USD 41,000 - 58,000; Full time

Benefits offered by this job

Medical dental & vision

401(k) plan

Life insurance

Paid time off

Job summary

Partnership HealthPlan of California seeks a Grievance & Appeals Case Analyst to investigate, manage, and resolve member grievances and appeals. You will handle a high-volume caseload, gather evidence, and communicate case status with members in a fast-paced environment.

The role requires strong investigative and communication skills, attention to detail, and proficiency with Microsoft Office. This is an onsite, contract position located in Fairfield, CA.

Qualifications

• Minimum of 1 year of experience in healthcare, health insurance, managed care, banking, finance, law enforcement, investigations, compliance, customer service, or a related field.
• Experience managing a high-volume workload or caseload.
• Strong written and verbal communication skills.
• Excellent customer service, investigative, and problem-solving abilities.
• Strong organizational skills and attention to detail.
• Proficiency with Microsoft Office (Word, Excel, Outlook).
• Health plan or managed care experience is preferred.
• Experience with Everest is a plus.

Responsibilities

• Manage approximately 50-60 active grievance and appeal cases at a time.
• Investigate member concerns related to denied services, access to care, provider issues, customer service concerns, and health plan benefits.
• Gather documentation and evidence to support case investigations.
• Communicate directly with members regarding case status, next steps, and outcomes.
• Work closely with internal departments, providers, and external partners to resolve cases.
• Draft acknowledgment letters, resolution letters, and other case-related correspondence.
• Maintain accurate case documentation and ensure compliance with regulatory timelines and requirements.
• Handle sensitive and occasionally escalated member interactions with professionalism and empathy.

Skills

Investigation skills

Communication

Organizational skills

Problem solving

High-volume workload management

Tools

Microsoft Office

Job description

Partnership HealthPlan of California seeks a Grievance & Appeals Case Analyst to investigate, manage, and resolve member grievances and appeals. You will handle a high-volume caseload, gather evidence, and communicate case status with members in a fast-paced environment.

The role requires strong investigative and communication skills, attention to detail, and proficiency with Microsoft Office. This is an onsite, contract position located in Fairfield, CA.