Appeals & Grievances I

Appeals & Grievances Specialist

Location: Sacramento. CA

Schedule: M-F, 8am-5pm

Position Overview

We are seeking an experienced Appeals & Grievances Specialist to support a healthcare organization in managing member complaints, appeals, and grievance cases. The ideal candidate will have a strong understanding of healthcare operations, regulatory requirements, and member advocacy, with the ability to investigate complex issues and deliver timely, compliant resolutions.

Key Responsibilities

• Manage the intake, investigation, and resolution of member appeals and grievances while ensuring compliance with regulatory requirements and established turnaround times.

• Research and evaluate issues related to benefits, claims, authorizations, referrals, enrollment, billing, utilization management, quality of care, and other health plan services.

• Assess case urgency and identify expedited requests, potential compliance concerns, privacy issues, fraud indicators, or quality-of-care matters.

• Collaborate with providers, hospitals, medical groups, and internal departments to gather information needed for case review and resolution.

• Maintain detailed and accurate case documentation, correspondence, and member communications.

• Draft customized acknowledgment and determination letters that clearly communicate outcomes, rationale, and member rights.

• Monitor trends and recommend process improvements to enhance member satisfaction and operational effectiveness.

• Support departmental initiatives, communications, audits, and special projects as needed.

Qualifications

• Minimum of 2 years of direct Appeals & Grievances experience within a healthcare setting.

• Health Plan, Managed Care, or HMO experience strongly preferred.

• Demonstrated experience handling appeal and grievance intake, investigations, case research, and resolution activities.

• Working knowledge of regulatory requirements and turnaround time standards, including DMHC, NCQA, and other applicable healthcare regulations.

• Experience with claims adjudication, referrals, authorizations, utilization management, or related healthcare operations is highly preferred.

• Strong analytical, organizational, and problem-solving skills.

• Excellent written communication and documentation abilities, with experience drafting professional member correspondence.

• Ability to manage multiple priorities in a fast-paced, deadline-driven environment while maintaining accuracy and compliance.

Preferred Skills

• Familiarity with Medicare, Medi-Cal, or commercial health plan processes.

• Experience working with cross-functional healthcare teams and external providers.

• Commitment to delivering exceptional member service and advocating for positive health outcomes.

Benefit offerings include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits and 401K plan. Our program provides employees the flexibility to choose the type of coverage that meets their individual needs. Available paid leave may include Paid Sick Leave, where required by law; any other paid leave required by Federal, State, or local law; and Holiday pay upon meeting eligibility criteria.

Pay Details: $22.00 to $25.00 per hour

Search managed by: Savannah Mckillip

Benefit offerings available for our associates include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits and a 401K plan. Our benefit offerings provide employees the flexibility to choose the type of coverage that meets their individual needs. In addition, our associates may be eligible for paid leave including Paid Sick Leave or any other paid leave required by Federal, State, or local law, as well as Holiday pay where applicable.

Equal Opportunity Employer/Veterans/Disabled

Military connected talent encouraged to apply

To read our Candidate Privacy Information Statement, which explains how we will use your information, please navigate to https://www.lhh.com/us/en/candidate-privacy

The Company will consider qualified applicants with arrest and conviction records in accordance with federal, state, and local laws and/or security clearance requirements, including, as applicable:

• The California Fair Chance Act
• Los Angeles City Fair Chance Ordinance
• Los Angeles County Fair Chance Ordinance for Employers
• San Francisco Fair Chance Ordinance

Massachusetts Candidates Only: It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.