Grievance & Appeals Specialist — Regulatory & Case Analysis

AppleOne Employment Services; Irvine (CA); On-site; USD 37,000 - 38,000; Full time

Job summary

AppleOne Employment Services is seeking Grievance and Appeals Specialists who enjoy research, documentation, regulatory accuracy, and clear written communication in a structured healthcare environment. This contract role offers focused training, exposure to multiple health plan products, cross-functional collaboration, and a supportive team focused on compliance, quality, and member experience.

The position is contract/temporary with pay rate of $27 to $27.20 per hour, located in Irvine, CA.

Qualifications

• 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 clearly.
• 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.

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 data, provider network information, and medical records.
• Prepare clear written determination communications that meet 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 URAC, NCQA, regulatory, and departmental standards.
• Serve as a liaison between grievance and appeals teams and internal business partners as needed.

Skills

Business writing

Regulatory knowledge

Healthcare claims

Provider networks

Analytical skills

Education

High school diploma

Job description

AppleOne Employment Services is seeking Grievance and Appeals Specialists who enjoy research, documentation, regulatory accuracy, and clear written communication in a structured healthcare environment. This contract role offers focused training, exposure to multiple health plan products, cross-functional collaboration, and a supportive team focused on compliance, quality, and member experience.

The position is contract/temporary with pay rate of $27 to $27.20 per hour, located in Irvine, CA.