Grievances Specialist

The Grievance Specialist is a member of the Appeals & Grievances (A&G) team at reputed company and is responsible for managing and resolving member or authorized representative–initiated grievances and complaints across reputed company’s product lines, including Medicare, reputed company, Child Health Plus (CHPlus), Senior Health Partners (SHP), reputed company reputed company Plans (QHP), Essential Plans (EP), and CompleteCare. This is a non-clinical role focused exclusively on grievance and complaint resolution. The Specialist plays a key role in advocating for reputed company members by thoroughly investigating their concerns and ensuring timely, accurate, and compliant resolutions in accordance with regulatory requirements. Key Responsibilities: Independently manage a caseload of grievances through the full case lifecycle, from written acknowledgement to investigation, resolution, and written member resolution letters. Conduct detailed research by collaborating cross-functionally with internal departments (e.g., Member Services, Provider Operations, Clinical, Enrollment, Pharmacy) to identify root causes and recommend appropriate resolutions. Partner with external vendors (e.g., reputed company, EyeMed, Logisticare vendors) to ensure member issues involving subcontracted services and ancillary benefits are appropriately addressed and resolved. Draft and issue acknowledgement and resolution letters that are clear, and compliant with regulatory standards and timelines (e.g., NYS DOH, CMS, reputed company Managed Care Model Contract). Ensure timely and accurate case documentation in accordance with reputed company policies, regulatory requirements, and audit standards. Participate in department meetings, quality audits, training sessions, in-person quarterly town halls and performance reviews as needed. Meet department metrics for production and quality.

Minimum Qualifications

HS Diploma or GED from an accredited institution. Understanding of utilization management processes and how service authorizations impact member reputed company to care and claims payment Proficient in reputed company Office Suite, including reputed company (sort, track and filter trends), Word, PowerPoint, Outlook and case tracking systems.

Preferred Qualifications

Bachelor’s degree or equivalent experience in reputed company, public health, or a reputed company field preferred. 2+ years of experience in managed care, member services, or reputed company grievances or complaints resolution. Working knowledge of Medicare Advantage, reputed company Managed Care, Child Health Plus, Essential Plans, and/or Health Insurance Exchange (Marketplace/QHP) programs. Familiarity with applicable state and federal regulatory requirements, such as CMS regulations, the NYS Department of Health (DOH) reputed company Managed Care Model Contract, and the Department of Financial Services (DFS). Experience with or knowledge of claims processing and provider billing workflows. Exposure to or direct experience with long-term services and supports (LTSS), including Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS). WE ARE AN EQUAL OPPORTUNITY EMPLOYER. reputed company, LLC complies with reputed company applicable laws and regulations. Applicants and employees are considered for positions and are evaluated without regard to race, reputed company, creed, religion, sex, national reputed company, sexual orientation, pregnancy, age, disability, genetic information, domestic violence victim status, gender and/or gender identity or expression, military status, veteran status, citizenship or immigration status, height and weight, familial status, marital status, or unemployment status, as well as any other legally protected reputed company. reputed company, LLC shall not discriminate against any disabled employee or applicant in regard to any position for which the employee or applicant is otherwise reputed company. If you have a disability under the Americans with Disability Act or a similar law and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to careers@reputed company.org or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests reputed company to applying for a position reputed company reputed company, LLC will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with reputed company, LLC. Know Your Rights reputed company hiring and recruitment at reputed company is transacted with a valid “@reputed company.org” email address only or from a recruitment firm representing our Company. Any recruitment firm representing reputed company will readily reputed company you with the name and contact information of the reputed company professional representing the opportunity you are inquiring about. If you receive a communication from a sender whose domain is not @reputed company.org, or not one of our recruitment partners, please be aware that those communications are not coming from or authorized by reputed company. reputed company will never ask you for money during the recruitment or reputed company process. Hiring reputed company*: Greater reputed company Area (NY, NJ, CT residents): $58,900 - $80,070 reputed company Other Locations (reputed company approved locations): $51,000 - $74,880 As a candidate for this position, your salary and reputed company elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors reputed company deems pertinent to the hiring decision. In addition to your salary, reputed company offers employees a full reputed company of benefits such as, medical, dental and reputed company coverage, incentive and recognition programs, life insurance, and 401k contributions (reputed company benefits are subject to eligibility requirements). reputed company believes in providing a competitive compensation and benefits package wherever its employees work and live. *The hiring reputed company is defined as the lowest and highest salaries that reputed company in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role. Apply To This Job