Remote Grievance & Appeals Specialist

Healthfirst; Tennessee; Remote; USD 51,000 - 75,000; Full time

Job summary

Healthfirst is seeking a Grievance Specialist for a 100% remote position. You will manage grievances across Medicare, Medicaid, CHPlus, SHP, QHP, EP, and CompleteCare, ensuring timely, compliant resolutions.

In this non-clinical role, you will collaborate with internal teams and external vendors, draft clear resolution letters, and maintain accurate documentation in line with regulatory standards and audits.

Qualifications

• HS Diploma or GED required.
• Understanding of utilization management processes and impact on access and payments.
• Proficient in Microsoft Office and case-tracking systems.

Responsibilities

• Independently manage a caseload of grievances through full lifecycle, from acknowledgement to resolution.
• Collaborate cross-functionally to identify root causes and recommended resolutions.
• Coordinate with external vendors to address subcontracted services and benefits issues.
• Draft and issue acknowledgement and resolution letters compliant with regulatory standards and timelines.
• Ensure timely, accurate case documentation per Healthfirst policies and audits.
• Participate in meetings, audits, training, and quarterly town halls as needed.
• Meet department production and quality metrics.

Skills

Utilization management knowledge

Regulatory knowledge

Microsoft Office Suite

Claims processing familiarity

LTSS exposure

Medicare/Medicaid knowledge

Education

HS Diploma or GED

Bachelor’s degree or equivalent in healthcare

Tools

Microsoft Office Suite

Job description

Healthfirst is seeking a Grievance Specialist for a 100% remote position. You will manage grievances across Medicare, Medicaid, CHPlus, SHP, QHP, EP, and CompleteCare, ensuring timely, compliant resolutions.

In this non-clinical role, you will collaborate with internal teams and external vendors, draft clear resolution letters, and maintain accurate documentation in line with regulatory standards and audits.