Remote Appeals & Grievance Specialist

Alignment Healthcare USA, LLC in; Orange (CA); Remote; USD 45,000 - 67,000; Full time

Job summary

Alignment Health is fully remote and seeks an Appeals & Grievance Coordinator to manage the day-to-day tracking of grievances, appeals, and complaints within the Member Services Department. You will act as the primary investigator and contact for member and provider grievances.

You will gather information, conduct investigations, prepare case histories for reviews, and ensure CMS guidelines and plan policies are followed.

Qualifications

• Two years’ data entry and general office experience required.
• Three years customer service experience required.
• Minimum 1 year in Member Services or similar experience.
• Bi-lingual (English/Spanish) preferred

Responsibilities

• Acknowledge receipts of grievances/appeals and document in CTM.
• Gather information from members/providers to determine resolution.
• Draft written correspondence per CMS guidelines.
• Investigate grievances/appeals in a non-biased, timely manner.
• Prepare case histories for committee reviews and board presentations.
• Ensure processing adheres to CMS guidelines and plan policy.
• Prepare reports and case files for reviews and audits.
• Identify training opportunities and process improvements related to grievance data.

Skills

Data entry

Customer service

Member Services

Bilingual (English/Spanish)

Education

High School Diploma or GED

Associate degree (A.A.)

Job description

Alignment Health is fully remote and seeks an Appeals & Grievance Coordinator to manage the day-to-day tracking of grievances, appeals, and complaints within the Member Services Department. You will act as the primary investigator and contact for member and provider grievances.

You will gather information, conduct investigations, prepare case histories for reviews, and ensure CMS guidelines and plan policies are followed.