Grievances & Appeals Specialist — Admin Claims (Remote)

Socket.dev; Atlanta (GA); On-site; USD 42,000 - 55,000; Full time

Benefits offered by this job

Medical benefits

Dental benefits

Vision benefits

Holidays

Sick time

Parental leave

401(k) plan

Life insurance

Disability insurance

Wellness time

Job summary

Oscar Health is seeking a Specialist, Admin Complaints, Grievances & Appeals to join the CGA & MPCT team. The role centers on comprehensive management and resolution of complex administrative grievances and appeals, focusing on non-clinical case resolution and regulatory compliance.

Based in a fully remote capacity, you will report to the CGA Team Lead and collaborate with internal departments to ensure timely, fair resolutions while supporting member satisfaction and retention.

Qualifications

• Experience in a regulated industry such as healthcare, insurance, or finance.
• Experience independently managing a demanding caseload with multi-step workflows.
• Experience directly managing escalated member/provider cases.
• Experience drafting formal written communications to members/providers.
• Experience working in a structured, workflow-driven environment.

Responsibilities

• Log initial assessment on complex or escalated grievances from members/providers.
• Conduct multi-faceted investigations using internal data, call logs, and correspondence.
• Reconstruct timelines involving prior authorizations, claims processing, and edits to determine causes.
• Collaborate with internal departments to obtain information for complete resolution.
• Determine a resolution strategy compliant with guidelines and escalate when needed.
• Draft clear resolution letters with regulatory elements.
• Maintain case files for audit trails in the case management system.
• Manage case timelines to meet federal and state deadlines.
• Ensure compliance with applicable laws and regulations.
• Perform other duties as assigned.

Skills

Regulated industry experience

Caseload management

Escalated cases handling

Written communication

Workflow-driven environment

Education

Bachelor's degree

Job description

Oscar Health is seeking a Specialist, Admin Complaints, Grievances & Appeals to join the CGA & MPCT team. The role centers on comprehensive management and resolution of complex administrative grievances and appeals, focusing on non-clinical case resolution and regulatory compliance.

Based in a fully remote capacity, you will report to the CGA Team Lead and collaborate with internal departments to ensure timely, fair resolutions while supporting member satisfaction and retention.