Grievances & Appeals Case Specialist

Blue Cross and Blue Shield of RI Careers; Providence (RI); Hybrid; USD 53,000 - 72,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

Tuition reimbursement

Student loan repayment

Paid time off

Flexible work arrangements

Bonuses

Investment plans

Volunteer time off

Job summary

Blue Cross & Blue Shield of Rhode Island (BCBSRI) is seeking a GAU Case Specialist in Providence to investigate, manage, and resolve member and provider grievances, complaints, and appeals. You will analyze policies, contracts, and records, document findings, and ensure timely determinations in compliance with CMS, NCQA, and internal requirements.

You will collaborate across departments, draft correspondence, and support audits and process improvements while maintaining accurate case

Qualifications

• Two+ years of relevant healthcare operations experience.
• Strong analytical and critical-thinking abilities.
• Excellent written and verbal communication skills.
• Ability to interpret regulatory requirements and policy language.
• Proficiency with Microsoft Office and case management systems.

Responsibilities

• Manage a caseload of grievances, complaints, and appeals from receipt to resolution.
• Review case documentation, claims information, and policies.
• Conduct thorough investigations to determine outcomes.
• Document activity and determinations in designated systems.
• Ensure timeliness and regulatory compliance.
• Collaborate with internal departments and external vendors as needed.
• Draft acknowledgment and determination letters.
• Support audit activities and cross-training.

Skills

Analytical skills

Communication skills

Organizational skills

MS Office / Case management systems

Education

Bachelor’s degree preferred

Tools

Case management software

Job description

Blue Cross & Blue Shield of Rhode Island (BCBSRI) is seeking a GAU Case Specialist in Providence to investigate, manage, and resolve member and provider grievances, complaints, and appeals. You will analyze policies, contracts, and records, document findings, and ensure timely determinations in compliance with CMS, NCQA, and internal requirements.

You will collaborate across departments, draft correspondence, and support audits and process improvements while maintaining accurate case