Remote Appeals and Grievances Analyst

Transforming Challenges Into Positive Change

Every complaint is an opportunity to drive meaningful improvement, and you’re the person who can turn a moment of frustration into lasting satisfaction. As a Remote Appeals and Grievances Analyst, you’ll shape the customer experience by ensuring each appeal or grievance receives the careful attention it deserves. Here, curiosity isn’t just valued—it’s essential. Your approach transforms regulatory complexities into transparent and fair resolutions, and your work elevates the standards for quality and equity across healthcare services. We move quickly, but you’ll always have space to focus deeply and thoughtfully on every case.

What You’ll Accomplish

When members raise concerns, your attention is immediate and your follow-through is thorough. Each investigation you lead clarifies facts, bridges communication gaps, and results in resolutions that matter—not just for one person, but for the future of our services. You’ll review appeals and grievances across multiple lines of business, analyze supporting documentation, and deliver concise, actionable findings that guide both policy and process change. Your written communication translates medical jargon into language everyone can understand, and you simplify complex ideas—whether it’s over Zoom or Slack.

Key Contributions

• Review member appeals and grievances with an open mind and rigorous attention to regulatory requirements, ensuring fair outcomes in every case.
• Analyze claims, benefit denials, pre-authorization requests, and medical necessity determinations, surfacing patterns that help us improve systems for everyone.
• Communicate with members, providers, and internal partners to gather facts and explain decisions, always centering empathy and clarity.
• Document each case in detail, providing a transparent trail of your reasoning and every action taken.
• Identify and escalate urgent or systemic issues to compliance and leadership, supporting positive change on a broader scale.
• Share insights that influence policy adjustments, workflow enhancements, and training for team members.

Your Approach & Tools

You thrive in a remote environment, managing competing deadlines while maintaining laser-sharp attention to detail. Digital workflow tools like Salesforce, Facets, and Microsoft Teams are second nature, and you’re always exploring new ways to automate repetitive steps. Your independent work style is balanced by your commitment to partnership—you’ll partner with compliance, case management, and clinical experts to create unified solutions. Adaptability is your superpower, whether a regulation changes or a complex scenario lands on your desk.

What Sets You Apart

• You turn regulatory documents into practical steps, not roadblocks.
• Your ability to translate policy into real-world impact builds trust and transparency with members and colleagues alike.
• Curiosity fuels your investigations, and your sense of accountability ensures nothing slips through the cracks.
• You’re the steady presence members depend on when stakes feel highest.

Required Experience & Skills

• Demonstrated experience in appeals, grievances, claims analysis, or healthcare compliance (remote experience preferred).
• Strong analytical mindset with a knack for connecting dots between policy, process, and people.
• You simplify complex concepts and make your reasoning accessible to all audiences.
• Familiarity with HIPAA, CMS guidelines, and state/federal regulations impacting healthcare appeals.
• Adept at digital workflow tools—comfortable navigating multiple systems and working independently from anywhere.
• Detail-oriented and self-motivated, balancing independence with team partnership.
• Dedication to safeguarding private data and demonstrating the utmost discretion in handling sensitive information.

Growth, Flexibility & Rewards

This is a fully remote role, designed for someone eager to contribute from anywhere while having the support and autonomy to excel. Your voice will shape ongoing quality improvement projects and new member experience initiatives. Alongside a competitive annual salary of $73,131, you’ll enjoy opportunities for ongoing learning, access to industry-leading resources, and a culture where every team member is empowered to drive innovation. We move quickly, but there’s always time set aside for thoughtful analysis and personal development.

Let’s Build Something Purposeful—Together

Are you ready to help us transform challenges into opportunities for lasting change? If your curiosity, compassion, and drive for clarity set you apart, we’d love to hear your story. Let’s make every member interaction count—starting now.