Appeals & Grievances Specialist

The Appeals & Grievances Specialist III role manages and resolves member complaints, grievances appeals, and some regulatory inquiries to ensure accurate, timely, and compliant outcomes. The role applies full proficiency in administrative, clinical, and regulatory processes to independently handle complex and high-risk cases.

Operating with minimal supervision, the Specialist III exercises advanced judgement in case evaluation, prioritization, and resolution. The position contributes to team effectiveness by supporting workflow consistency, providing guidance to peers, and identifying opportunities to improve processes and compliance outcomes. The role plays a key part in maintaining service quality and regulatory adherence across the Appeals & Grievances function.