Remote Grievance Resolution Specialist

HealthFirst; United States; Remote; USD 51,000 - 80,000; Full time

Job summary

HealthFirst is seeking a Grievance Specialist for the 100% remote Appeals & Grievances team. You will manage member grievances end-to-end, investigate with cross-functional partners, and ensure timely, compliant resolutions within regulatory standards.

The role emphasizes advocacy for members and meticulous documentation. Minimum qualifications include a HS Diploma and knowledge of utilization management; preferred candidates hold a Bachelor’s degree and prior managed care experience.

Qualifications

• HS Diploma or GED is required.
• Understanding of utilization management processes and how service authorizations impact member access to care and claims payment.
• Proficient in Microsoft Office Suite (Excel, Word, PowerPoint, Outlook) and case tracking systems.

Responsibilities

• Independently manage a caseload of grievances through the full lifecycle from acknowledgement to resolution.
• Collaborate with internal departments to identify root causes and recommend appropriate resolutions.
• Coordinate with external vendors to address issues involving subcontracted services.
• Draft and issue acknowledgement and resolution letters compliant with regulatory standards and timelines.
• Ensure timely and accurate case documentation per policies and audit standards.
• Participate in department meetings, audits, training, and performance reviews.
• Meet department production and quality metrics.

Skills

Utilization management

Microsoft Office

Case tracking systems

Education

Bachelor’s degree preferred

Tools

DentaQuest

EyeMed

Logisticare

Job description

HealthFirst is seeking a Grievance Specialist for the 100% remote Appeals & Grievances team. You will manage member grievances end-to-end, investigate with cross-functional partners, and ensure timely, compliant resolutions within regulatory standards.

The role emphasizes advocacy for members and meticulous documentation. Minimum qualifications include a HS Diploma and knowledge of utilization management; preferred candidates hold a Bachelor’s degree and prior managed care experience.