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Grievance & Appeals Resolution Specialist
Clever Care Health Plan —Huntington Beach, CA
- $26 - $32 an hour
- Full-time
- Hybrid work
- Background check
- Microsoft Excel
- Writing skills
2d
Grievance Resolution Specialist
Kinetic Personnel Group, Inc. —Orange, CA
- $25 - $37 an hour
- Temporary
- Spanish
- Microsoft Outlook
- Writing skills
- Paid time off
- Paid sick time
Quick Apply
11d
QUALITY SPECIALIST - Problem Resolution Coordinator
Pilkington North America Inc. —Shelbyville, IN
- Computer literacy
- English
- Mid-level
Quick Apply
Pricing Resolution Specialist
MedReview —Remote
- $26.50 - $30.00 an hour
- Full-time
- Microsoft Excel
- Microsoft Outlook
- 5 years
Quick Apply
Resolution Specialist - REMOTE - US
Holland America Line —Seattle, WA
- $18 an hour
- 8 hour shift
- Remote
- Computer literacy
- Computer skills
- Communication skills
- Employee stock purchase plan
- Health insurance
Medicare Account Resolution Specialist - Digitech - Remote
Sarnova —Remote
- Full-time
- Remote
- Microsoft Outlook
- Word processing
- Computer literacy
- 401(k)
Quick Apply
Implementation Specialist
PatientNow —Remote
- $60,000 - $72,000 a year
- Full-time
- Remote
- Mid-level
- Organizational skills
- 2 years
Quick Apply
Account Resolution Specialist - Insurance HMOs - Digitech - Remote
Sarnova —Remote
- Full-time
- Remote
- Microsoft Outlook
- Word processing
- Research
- 401(k)
Quick Apply
Provider Research & Resolution Specialist - Remote
NTT DATA —Dallas, TX
- $16.75 an hour
- Remote
- Microsoft Excel
- Microsoft Outlook
- HIPAA
- Health savings account
- AD&D insurance
Quick Apply
Claims Resolution Specialist
Claritev —Remote
- $20.23 an hour
- Full-time
- HIPAA
- Research
- Mid-level
- Paid parental leave
- Employee stock purchase plan
Executive Resolution Specialist - Home Solutions
Assurant —Remote
- $20.96 - $34.59 an hour
- Full-time
- Remote
- Spanish
- Marketing
- Writing skills
Patient Resolution Specialist - Remote
Med-Metrix —Remote
- Full-time
- Remote
- HIPAA
- Research
- High school diploma or GED
Dispute Resolution Specialist II
Claritev —Remote
- $19 - $21 an hour
- Full-time
- Microsoft Excel
- Microsoft Outlook
- HIPAA
- Paid parental leave
- Employee stock purchase plan
(REMOTE) Dental Claims Resolution Specialist 1
Widescope Consulting and Contracting Services LLC —Powder Springs, GA
- $17.75 an hour
- Full-time
- Remote
- Entry level
- Paid training
- Paid holidays
Insurance Account Resolution Specialist - Digitech - Remote
Sarnova —Remote
- Full-time
- Remote
- Microsoft Outlook
- Research
- Mid-level
- 401(k)
Quick Apply
Appeals Specialist II
MedReview —Remote
- $50,000 - $55,000 a year
- Full-time
- Remote
- Research
- Mid-level
- Microsoft Office
- Commuter assistance
- Health insurance
Quick Apply
Order Operations Specialist
Order.co —Chicago, IL
- $22 - $26 an hour
- Full-time
- Remote
- Customer service
- Continuous improvement
- Data entry
- Health insurance
- Dental insurance
Quick Apply
CLAIMS SPECIALIST
JR Services —Remote
- Full-time
- Remote
- Customer service
- Communication skills
- Entry level
- Vision insurance
Provider Data Resolution Specialist (MST, PST hours only)
TriWest Healthcare Alliance —Phoenix, AZ
- $41,000 - $44,000 a year
- Full-time
- Microsoft Excel
- Microsoft Outlook
- Computer literacy
- AD&D insurance
- Disability insurance
6d
Compliance Support Specialist
TRES HEALTH INC —Remote
- Remote
- Research
- Mid-level
- Office

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Grievance & Appeals Resolution Specialist

Clever Care Health Plan -
Huntington Beach, CA

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Job Details

Full-time
$26 - $32 an hour
2 days ago

Qualifications

Healthcare dispute resolution
Appeals
Computer operation
Microsoft Excel
Medicare
Insurance dispute resolution
Caseload management
Writing skills
CMS
Filing
CMS regulatory compliance
Medicare regulations
Medical insurance appeals management
Data interpretation
Regulatory submissions
Typing
Productivity software
Insurance claims appeal handling
Customer complaint resolution

Full Job Description

Applicants must reside in California

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We? ✨

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.

Why Join Us?

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

The Appeals & Grievances Resolution Specialist supports the intake, investigation, and resolution of member grievances, appeals, provider disputes, and complaints in accordance with CMS regulations, NCQA standards, and applicable state and contractual requirements.

This role independently manages assigned cases within established guidelines, applies sound analytical judgment to resolve non-clinical matters, collaborates with clinical and operational partners, and ensures timely, accurate, and compliant case resolution. The Resolution Specialist is accountable for meeting CMS turnaround time requirements, maintaining audit-ready documentation, supporting CMS Complaints Tracking Module (CTM) activities, and contributing to quality improvement and Star Ratings performance through effective trend identification and member-centered communication.

The Appeals & Grievances Resolution Specialist may also assist the Member Services department with overflow calls and outbound campaigns as business needs require.

Essential Functions & Job Responsibilities

Intake, investigate, document, and resolve member grievances, appeals, and provider disputes in compliance with CMS, NCQA, state, and contractual requirements.
Ensure cases are processed within required turnaround times and accurately tracked through resolution.
Apply sound, fact-based decision-making to resolve non-clinical complaints and appeals.
Communicate with members and providers to obtain additional information, explain decisions, and provide clear written and verbal case outcomes.
Support intake, investigation, and resolution of CMS Complaints Tracking Module (CTM) cases, ensuring timely, accurate, and compliant responses.
Prepare appeal summaries, determination letters, and supporting documentation for internal review, CMS universes, audits, and oversight entities.
Coordinate with Medical Management, Claims, Provider Relations, Compliance, and other departments to facilitate timely case resolution.
Maintain accurate, complete, and compliant documentation in case tracking systems.
Identify and analyze trends and root causes in grievances, appeals, and complaints, and report findings to leadership to support quality improvement initiatives and reduce repeat issues.
Maintain audit-ready case files and support CMS audit and universe submission activities, including data validation, case review, and response to regulatory requests.
Perform quality audits and monitoring activities; report findings and recommend corrective actions.
Assist with development and maintenance of desk-level procedures, job aids, and training materials.
Support HEDIS-related activities as assigned, including data entry, provider outreach, and claims research.
Assist Member Services with overflow calls and outbound campaigns during high-volume periods, as needed.
Prepare reports and summaries for internal committees, compliance meetings, and leadership review.
Represent the organization professionally and compassionately when interacting with members, providers, and internal partners.

Qualifications

Required:

2+ years of experience in Medicare Advantage Grievances & Appeals operations
Working knowledge of CMS regulations governing appeals, grievances, and CTM
Experience with case tracking systems and regulatory documentation requirements
Strong analytical, problem-solving, and decision-making skills
Excellent written and verbal communication skills
Ability to manage multiple cases and priorities in a fast-paced environment
Intermediate proficiency in Microsoft Word, Excel, and PowerPoint
Ability to type at least 40 WPM

Preferred:

Knowledge of medical and claims coding (CPT, HCPCS, ICD-10, DRG, Revenue Codes)
Experience supporting CMS audits, universes, or regulatory submissions
Bilingual in Korean, Vietnamese, or Mandarin

Wage Range: $26.00 to $32.00 per hour

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

Must be able to travel when needed or required
Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

#LI-Hybrid

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Refine Your Search

resolution specialist jobs

Grievance & Appeals Resolution Specialist

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QUALITY SPECIALIST - Problem Resolution Coordinator

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Implementation Specialist

Account Resolution Specialist - Insurance HMOs - Digitech - Remote

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Claims Resolution Specialist

Executive Resolution Specialist - Home Solutions

Patient Resolution Specialist - Remote

Dispute Resolution Specialist II

(REMOTE) Dental Claims Resolution Specialist 1

Insurance Account Resolution Specialist - Digitech - Remote

Appeals Specialist II

Order Operations Specialist

CLAIMS SPECIALIST

Provider Data Resolution Specialist (MST, PST hours only)

Compliance Support Specialist

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