Remote Health Appeals & Grievances Specialist

Harbor Health; Texas; Hybrid; USD 65,000 - 90,000; Full time

Benefits offered by this job

Fully remote work environment

Competitive salary and benefits

Generous PTO

10 paid holidays

Medical, Dental, Vision Insurance

401(k) Investment Plan

Professional development and growth

Transparent and unique culture

Collaborative and dynamic work enviro

Job summary

Harbor Health in Texas seeks an Appeals & Grievances Specialist to investigate, process, and resolve member and provider complaints, grievances, and appeals. This fully remote role focuses on Texas IFP/Marketplace and large-group products, ensuring timely investigations and compliant determinations.

The candidate will review documents, communicate with stakeholders, and draft clear letters. Experience with CMS/NCQA regulations and HIPAA is preferred.

Qualifications

• Minimum 2–4 years of operational experience within a managed care organization or equivalent.
• 1–2 years dedicated to health plan complaints, grievances, or appeals.
• Solid knowledge of Commercial health insurance products including Large Group and IFP/ACA/Exchange.
• Familiarity with federal/state appeal regulations and external review procedures.
• Ability to translate complex medical/benefits terminology into member-friendly explanations.

Responsibilities

• Manage active pipeline of member/provider grievances, pre/post-service appeals, and regulatory complaints from intake to resolution.
• Investigate issues by reviewing plan documents, claims history, medical and billing records, and prior logs.
• Coordinate with internal departments to evaluate disputed issues and ensure proper adjudication.
• Communicate with members/providers to gather information needed for reviews.
• Maintain audit-ready case files and prepare summaries for IROs/IDR filings when required.
• Document every step in the core case management system and monitor adherence to CMS/NCQA standards.

Skills

Managed care experience

Strong written communication

HIPAA compliance

Autonomous work style

Attention to detail

Education

High School Diploma or GED

Associate or Bachelor’s degree in Healthcare Administration, Business, Communications, or related field

Tools

AxisCore platform

Claims processing modules

Job description

Harbor Health in Texas seeks an Appeals & Grievances Specialist to investigate, process, and resolve member and provider complaints, grievances, and appeals. This fully remote role focuses on Texas IFP/Marketplace and large-group products, ensuring timely investigations and compliant determinations.

The candidate will review documents, communicate with stakeholders, and draft clear letters. Experience with CMS/NCQA regulations and HIPAA is preferred.