Appeals & Grievances Specialist

Appeals & Grievances Specialist

Harbor Health

POSITION OVERVIEW

We are seeking a detail-driven, member-centric Appeals & Grievances (A&G) Specialist to investigate, process, and resolve member and provider complaints, grievances, and appeals. This fully remote position focuses primarily on supporting our Texas fully insured Individual & Family Plan (IFP/Marketplace) and large group (25+ employees) commercial products.

The specialist is responsible for conducting thorough end-to-end case investigations, collaborating with internal clinical and claims teams, ensuring adherence to statutory turn-around times (TAT), and drafting clear, compliant determination letters. Direct experience handling health plan complaints and familiarity with core administrative platforms are strongly preferred.

POSITION DUTIES & RESPONSIBILITIES

Case Investigation & Adjudication

• Manage an active pipeline of member and provider grievances, pre-service appeals, post-service claim appeals, and regulatory complaints from intake through resolution.

• Investigate underlying issues by reviewing plan documents (Evidence of Coverage, Summary of Benefits, Provider Manuals), claims history, medical records, billing records, and prior customer service contact logs.

• Serve as the liaison between members, providers, and internal departments to resolve issues effectively, ensuring the integrity of the appeals and grievance process and compliance with CMS, NCQA, and state regulatory requirements.

• Make appropriate outbound contact to members or providers to collect all relevant information to complete reviews.

• Coordinate with internal Harbor Health departments to evaluate disputed issues and ensure appropriate adjudication.

• Process grievances and appeals within statutory timeframes.

Compliance & Written Communication

• Compose written correspondence in clear, plain language tailored to the member's literacy level while addressing all specific grievance/appeal points.

• Maintain complete, audit-ready case files with all relevant documentation, rationales, internal notes, and correspondence logs.

• Prepare case summaries and documentation packets for Independent Review Organizations (IROs) or Independent Dispute Resolution (IDR) filings when cases escalate.

Operations & Platform Utilization

• Document every step of the investigation and resolution process inside the core case management system.

• Utilize health plan processing platforms to look up claims data, review call center customer service notes, verify enrollment, and track grievance statuses.

• Identify operational trends, root-cause billing/adjudication errors, or systemic member pain points and escalate them to leadership for process improvement.

DESIRED PROFESSIONAL SKILLS & EXPERIENCE

Required Experience & Skills

• High School Diploma or GED required; Associate or Bachelor’s degree in Healthcare Administration, Business, Communications, or a related field preferred.

• Minimum of 2–4 years of operational experience within a managed care organization (MCO), health plan, or Third-Party Administrator (TPA), with at least 1–2 years dedicated to health plan complaints, grievances, or appeals.

• Solid working knowledge of Commercial health insurance products, including Large Group and Individual & Family Plans (IFP/ACA/Exchange).

• Familiarity with federal and state appeal regulations, prompt-pay standards, grievance classification taxonomies, and external review procedures.

• Strong written communication skills, with proven ability to translate complex medical and benefits terminology into member-friendly explanations.

• Proven ability to work autonomously, prioritize competing deadlines, and maintain strict confidentiality (HIPAA compliance) in a home-office environment.

Preferred Qualifications

• Experience with AxisCore platform, call center/customer service logging, grievance tracking, or claims processing modules.

• Prior experience interacting with external Independent Review Organizations (IROs) or responding to Independent Dispute Resolution (IDR) filings.

• Experience navigating both medical/clinical appeal workflows and administrative/claims billing dispute workflows.

WHAT WE OFFER

• Fully remote work environment

• Competitive salary and benefits package

• Generous PTO

• 10 paid holidays

• Medical, Dental, and Vision Insurance

• 401(k) Investment Plan

• Professional development and growth opportunities

• A transparent and unique culture

• Collaborative and dynamic work environment

COMPANY OVERVIEW

At Harbor Health, we're transforming healthcare in Texas through collaboration and innovation. We're seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you're ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!

EQUAL EMPLOYMENT OPPORTUNITY

Harbor Health is an Equal Opportunity Employer. We celebrate diversity and are committed to building an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic.