Appeals and Grievances Specialist

<p>Sidecar Health is redefining health insurance. Our mission is to make excellent healthcare affordable and accessible for everyone. We know that to accomplish this lofty mission, we need driven people who will make things happen.</p>

<p>The passionate people who make up Sidecar Health’s team come from all over, with backgrounds as tech leaders, policy makers, healthcare professionals, and beyond. And they all have one thing in common—the desire to fix a broken system and make it more personalized, affordable, and transparent.</p>

<p>If you want to use your talents to transform healthcare in the United States, come join us!</p>

<p><strong>About the Role</strong></p>

<p><span data-contrast="none"><span data-ccp-parastyle="Body Text">As an Appeals and Grievances Specialist, </span><span data-ccp-parastyle="Body Text">you'll</span><span data-ccp-parastyle="Body Text"> own the end-to-end handling of member and provider appeals and grievances</span><span data-ccp-parastyle="Body Text">,</span><span data-ccp-parastyle="Body Text"> investigating cases, coordinating with internal teams, and delivering clear, well-reasoned resolutions within regulatory timelines.</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></p>

<p><span data-contrast="none"><span data-ccp-parastyle="Body Text">This role sits at the intersection of advocacy, compliance, and operations. </span><span data-ccp-parastyle="Body Text">You'll</span><span data-ccp-parastyle="Body Text"> work directly with members and providers who need someone to take their concern seriously, dig into the details, a</span><span data-ccp-parastyle="Body Text">nd get</span><span data-ccp-parastyle="Body Text"> them an answer they can trust. </span><span data-ccp-parastyle="Body Text">You'll</span><span data-ccp-parastyle="Body Text"> report to the Director, Quality and Continuous Improvement, and work closely with QA, Claims, Clinical, and Provider Relations to reach fair, well-documented outcomes.</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></p>

<p><strong><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}">What You'll Do</span></strong></p>

<ul>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Intake, triage, and manage a caseload of member and provider appeals and grievances from submission through resolution</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Investigate each case thoroughly</span><span data-ccp-parastyle="Body Text">,</span><span data-ccp-parastyle="Body Text"> reviewing claims history, benefit determinations, clinical documentation, and prior correspondence</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Apply</span><span data-ccp-parastyle="Body Text"> plan </span><span data-ccp-parastyle="Body Text">documents, state and federal regulations, and Sidecar Health policy to reach </span><span data-ccp-parastyle="Body Text">accurate</span><span data-ccp-parastyle="Body Text">, well-documented determinations</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Draft clear, compliant resolution letters and member and provider communications in Sidecar Health's brand voice</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Track all cases and deadlines to ensure compliance with state and federal turnaround time requirements</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Coordinate with Claims, Clinical, Provider Relations, and Legal teams to gather information and resolve complex cases</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Identify</span><span data-ccp-parastyle="Body Text"> escalati</span><span data-ccp-parastyle="Body Text">on risks and loop in leadership or the Grievance Committee when a case requires second-level review</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Spot patterns in appeals and grievances that point to upstream process, system, or communication issues, and flag them to leadership</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Maintain </span><span data-ccp-parastyle="Body Text">accurate</span><span data-ccp-parastyle="Body Text"> records in the case management s</span><span data-ccp-parastyle="Body Text">ystem </span><span data-ccp-parastyle="Body Text">to support audits and regulatory reporting</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Contribute to process improvements, SOP updates, and knowledge base articles for the appeals and </span><span data-ccp-parastyle="Body Text">grievance’s</span><span data-ccp-parastyle="Body Text"> function</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

</ul>

<p><strong><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}">What You'll Bring</span></strong></p>

<ul>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Bachelor's d</span><span data-ccp-parastyle="Body Text">egree </span><span data-ccp-parastyle="Body Text">require</span><span data-ccp-parastyle="Body Text">d</span><span data-ccp-parastyle="Body Text">, in a relevant field such as healthcare administration, business, public health, or a related discipline</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">3</span><span data-ccp-parastyle="Body Text">+ years</span><span data-ccp-parastyle="Body Text"> of experience in appeals and grievances, claims adjudication, </span><span data-ccp-parastyle="Body Text">utilization</span><span data-ccp-parastyle="Body Text"> review, or a related health insurance operations role</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Working knowledge of health insurance regulatory requirements for appeals and grievances (state DOI requirements, ERISA, ACA as applicable)</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Strong analytical skills</span><span data-ccp-parastyle="Body Text">,</span><span data-ccp-parastyle="Body Text"> comfortable reading claims data, plan documents, and clinical notes to form a defensible conclusion</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Excellent written communication skills; able to explain </span><span data-ccp-parastyle="Body Text">complex</span><span data-ccp-parastyle="Body Text"> determination in plain, empathetic language</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">A track record</span><span data-ccp-parastyle="Body Text"> of </span><span data-ccp-parastyle="Body Text">managing</span><span data-ccp-parastyle="Body Text"> a caseload independently and meeting hard deadlines</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Comfort working across systems and teams to track down the information </span><span data-ccp-parastyle="Body Text">a case </span><span data-ccp-parastyle="Body Text">need</span><span data-ccp-parastyle="Body Text">s</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">A member-first mindset, balanced with rigorous attention to policy and compliance</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

</ul>

<p><strong><span data-contrast="none">Nice to haves</span></strong><span data-ccp-props="{"335559738":320,"335559739":140,"335572079":8,"335572080":4,"335572081":13197326,"469789806":"single"}"> </span></p>

<ul>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Experience with Genesys Cloud, Salesforce, or similar case management and CRM platforms</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Familiarity with Medicare Advantage or ACA marketplace appeals processes</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

<li><span data-contrast="none"><span data-ccp-parastyle="Body Text">Prior experience in a fast-growing or start-up health insurance environment</span></span><span data-ccp-props="{"201341983":0,"335559739":90,"335559740":300}"> </span></li>

</ul>

<p><strong>What You'll Get</strong></p>

<ul>