Appeals & Grievances Specialist

Western Health Advantage (WHA)
Location: Hybrid/Sacramento, California
Hourly Range: $22.00 – $25.00

"Our purpose is strong, our impact is lasting, join us on the journey"
Western Health Advantage

Western Health Advantage is seeking a detail-oriented and highly organized Appeals & Grievances Specialist I to support the accurate, timely, and compliant processing of member appeals and grievances. This role is integral to ensuring regulatory adherence while advocating for members and delivering exceptional service in a fast-paced environment.

The Appeals & Grievances Specialist I is responsible for applying comprehensive knowledge of WHA’s practices, policies, benefit guidelines, contractual agreements, and regulatory requirements in the review and processing of appeals and grievances.

This position ensures compliance with all applicable regulatory standards and time frames, including those established by the California Department of Managed Health Care (DMHC), National Committee for Quality Assurance (NCQA) accreditation standards, and HIPAA/PHI privacy regulations.

The role requires extensive collaboration with internal departments and external partners, including medical groups, providers, authorized representatives, brokers, and hospital systems.

• Serve as the assigned specialist responsible for intake, research, and investigation of member appeals and grievances.

• Represent the member’s interests from initial triage through resolution.

• Classify and process appeals and grievances across a broad range of categories, including but not limited to:

  • Enrollment/disenrollment

  • Premium billing

  • Access and care coordination

  • Medical and pharmacy benefits

  • Prior authorizations

  • Claims processing and reimbursement

  • Deductibles and out-of-pocket maximums

  • Utilization management

  • Quality of care and compliance matters

• Ensure cases meet all regulatory guidelines and mandated time frames.

• Identify case urgency, expedited requests, and potential quality-of-care concerns.

• Recognize potential violations including PHI/HIPAA breaches, fraud, contract concerns, and statute of limitations issues.

• Notify members of expedited request determinations and their right to contact the DMHC when applicable.

• Conduct outreach to members and authorized representatives to obtain additional information as needed.

• Collaborate with internal departments and contracted entities to gather pertinent documentation and medical records.

• Evaluate information received to ensure sufficiency for Plan determination.

• Maintain ongoing follow-up to secure timely and complete responses.

• Maintain accurate, thorough documentation of case activity, communications, medical records, and committee decisions.

• Customize acknowledgement letters summarizing member concerns.

• Assist in drafting resolution letters aligned with benefit guidelines and/or medical necessity determinations, including member education.

• Identify and report trends or recurring issues during intake.

• Participate in process improvement initiatives and training enhancements.

• Support team members and assist the A&G Coordinator with monitoring incoming and outgoing communications (email, mail, fax).

• Perform additional duties and special projects as assigned.

• High School Diploma required.

• Minimum two (2) years of experience in appeals and grievances within the healthcare industry; HMO experience strongly preferred.

• Experience with HMO claims adjudication, referrals, and authorizations (utilization management) preferred.

• Working knowledge of regulatory requirements related to DMHC, NCQA, and HIPAA/PHI privacy standards.

• Intermediate computer proficiency, including Microsoft Word and Excel.

• Strong written and verbal communication skills with the ability to draft clear, member-focused correspondence.

• Ability to manage multiple cases and priorities in a fast-paced environment while maintaining attention to detail.

This role offers the opportunity to make a meaningful impact…