Grievance Specialist – Remote

Healthfirst; United States; Remote; USD 55,000 - 75,000; Full time

Benefits offered by this job

Remote work

Flexible schedule

Job summary

Healthfirst is seeking a Grievance Specialist to join its Appeals & Grievances team in a fully remote position. You will manage and resolve member complaints across Medicare, Medicaid, and other Healthfirst programs, coordinating with internal teams and external partners to ensure timely, compliant resolutions.

The role emphasizes detailed investigation, accurate documentation, and clear communication with members. Strong MS Office skills and knowledge of healthcare programs are essential.

Qualifications

• Bachelor's degree or equivalent in healthcare, public health, or related field preferred.
• Strong written and verbal communication skills required.
• Proficiency in Microsoft Office and case tracking systems.
• Understanding of utilization management and its impact on access and claims.
• Ability to work independently in a remote environment.
• Experience with LTSS (long-term services and supports) is a plus.

Responsibilities

• Manage grievance cases from acknowledgement through resolution and closure.
• Investigate concerns by coordinating with internal departments and external partners.
• Prepare compliant resolution communications and notifications to members.
• Maintain accurate case documentation per policies and regulatory guidelines.
• Monitor progress and ensure timely completion of cases.
• Participate in team meetings, quality reviews, and training.

Skills

Written and verbal communication

MS Office proficiency

Case tracking systems

Utilization management understanding

Ability to manage multiple cases

Remote work discipline

Education

Bachelor's degree or equivalent in healthcare/public health/related field

Tools

Microsoft Office Suite

Case tracking systems

Job description

Healthfirst is seeking a Grievance Specialist to join its Appeals & Grievances (A&G) team in a fully remote position. The role focuses on managing and resolving member or authorized representative complaints and grievances across various healthcare programs, including Medicare, Medicaid, Child Health Plus, Commercial Plans, and other Healthfirst products.

The selected candidate will be responsible for investigating concerns, coordinating with internal departments and external partners, preparing compliant resolution communications, and ensuring cases are handled accurately and within required timelines. This position plays an important role in supporting members and improving healthcare service experiences.

Key Responsibilities:

• Manage assigned grievance cases throughout the complete lifecycle, including acknowledgement, investigation, resolution, and member communication.
• Conduct detailed research by collaborating with internal teams such as Member Services, Provider Operations, Clinical, Enrollment, and Pharmacy departments.
• Work with external vendors and service partners to resolve member concerns related to additional benefits and contracted services.
• Prepare clear acknowledgement and resolution letters while ensuring compliance with regulatory requirements.
• Maintain accurate case documentation according to company policies, audit standards, and regulatory guidelines.
• Monitor case progress and ensure timely completion of assigned grievances.
• Participate in team meetings, quality reviews, training sessions, and performance evaluations.
• Achieve department productivity and quality performance targets.

Requirements:

• High School Diploma or GED from an accredited institution.
• Understanding of utilization management processes and how service authorizations impact healthcare access and claims payments.
• Proficiency in Microsoft Office Suite, including Excel, Word, PowerPoint, Outlook, and case tracking systems.
• Strong written and verbal communication skills.
• Ability to manage multiple cases and meet deadlines in a remote work environment.
• Strong knowledge of:
  • Healthcare grievance and complaint resolution processes.
  • Medicare Advantage, Medicaid Managed Care, Child Health Plus, Essential Plans, and Qualified Health Plans.
  • Healthcare claims processing and provider billing workflows.
  • CMS regulations and applicable healthcare compliance requirements.
• Bachelor's Degree or equivalent experience in healthcare, public health, or a related field is preferred.
• Experience with long-term services and supports (LTSS), including PCS and CDPAS, is an advantage.
• High School Diploma or GED Required; Bachelor's Degree in Healthcare, Public Health, or Related Field Preferred