Remote Case Specialist – Grievances & Appeals Expert

Blue Cross & Blue Shield of Rhode Island; Providence (RI); Hybrid; USD 53,000 - 72,000; Full time

Benefits offered by this job

Remote and hybrid opportunities

Tuition reimbursement

Student-loan repayment assistance

Health insurance

Dental insurance

Vision insurance

Bonuses and investment plans

Job summary

Blue Cross & Blue Shield of Rhode Island in Providence seeks a GAU Case Specialist to investigate, manage, and resolve member and provider grievances, complaints, and appeals in line with CMS, NCQA, HIPAA, and internal policies.

The role requires reviewing documentation, conducting thorough investigations, and documenting activity in our case systems to ensure timely, accurate determinations and compliant, audit-ready records.

Qualifications

• Strong analytical and critical-thinking abilities.
• Excellent written and verbal communication skills.
• Ability to interpret policies, guidelines, and benefit plans.

Responsibilities

• Manage a caseload of grievances, complaints, and appeals from receipt through final resolution.
• Review case documentation, claims information, benefit plans, and supporting records.
• Conduct thorough investigations to determine appropriate outcomes.
• Document all activity, research, and determinations in designated systems.
• Ensure compliance with regulatory timeliness and internal requirements.
• Communicate findings clearly to members, providers, and internal stakeholders.

Skills

Analytical thinking

Strong communication

Detail oriented

Independent worker

Education

Bachelor's degree preferred

Job description

Blue Cross & Blue Shield of Rhode Island in Providence seeks a GAU Case Specialist to investigate, manage, and resolve member and provider grievances, complaints, and appeals in line with CMS, NCQA, HIPAA, and internal policies.

The role requires reviewing documentation, conducting thorough investigations, and documenting activity in our case systems to ensure timely, accurate determinations and compliant, audit-ready records.