Appeals and Grievances Specialist

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $65k - $75k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

Sidecar Health

WebsiteLinkedInAll Job Openings

201 - 500 employees

Founded 2018

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Sidecar Health is a health insurance company that provides comprehensive major medical insurance with upfront pricing and no network restrictions or referral requirements. Their goal is to put employees in control of their healthcare by giving them a clear budget for care and allowing them to choose any doctor without surprise costs. They emphasize access to prescriptions without limitations and protection for unplanned care. Sidecar Health also offers transparent pricing and the option for members to save money if they find providers who charge less than their plan pays. Their offerings include individualized access plans and employer plans, ensuring members always have a choice of qualified doctors.

📋 Description

• Own the end-to-end handling of member and provider appeals and grievances • Intake, triage, and manage a caseload of member and provider appeals and grievances from submission through resolution • Investigate cases by reviewing claims history, benefit determinations, clinical documentation, and prior correspondence • Apply plan documents, state and federal regulations, and Sidecar Health policy to reach accurate, well-documented determinations • Draft clear, compliant resolution letters and member and provider communications • Track cases and deadlines to ensure compliance with state and federal turnaround time requirements • Coordinate with Claims, Clinical, Provider Relations, and Legal teams to resolve complex cases • Identify escalation risks and involve leadership or the Grievance Committee when second-level review is required • Identify patterns indicating upstream process, system, or communication issues and flag them to leadership • Maintain accurate case management system records for audits and regulatory reporting • Contribute to process improvements, SOP updates, and knowledge base articles

🎯 Requirements

• Bachelor's degree required in healthcare administration, business, public health, or a related discipline • 3+ years of experience in appeals and grievances, claims adjudication, utilization review, or a related health insurance operations role • Working knowledge of health insurance regulatory requirements for appeals and grievances, including state DOI requirements, ERISA, and ACA as applicable • Strong analytical skills and ability to read claims data, plan documents, and clinical notes to form defensible conclusions • Excellent written communication skills and ability to explain complex determinations in plain, empathetic language • Track record of independently managing a caseload and meeting hard deadlines • Comfort working across systems and teams to obtain case information • Member-first mindset with rigorous attention to policy and compliance • Experience with Genesys Cloud, Salesforce, or similar case management and CRM platforms (nice to have) • Familiarity with Medicare Advantage or ACA marketplace appeals processes (nice to have) • Prior experience in a fast-growing or start-up health insurance environment (nice to have)

🏖️ Benefits

• Competitive salary ($65,000 - $75,000) • Bonus opportunity • Equity package • Comprehensive Medical, Dental, and Vision benefits • A 401k retirement plan • Paid vacation and company holidays • Opportunity to make an impact at a rapidly growing mission-driven company transforming healthcare in the U.S.