[Hiring] Appeals & Grievances Specialist @The Harbor Health Team

Role Description

We are seeking a detail-driven, member-centric Appeals & Grievances (A&G) Specialist to investigate, process, and resolve member and provider complaints, grievances, and appeals. This fully remote position focuses primarily on supporting our Texas fully insured Individual & Family Plan (IFP/Marketplace) and large group (25+ employees) commercial products.

• Conduct thorough end-to-end case investigations.
• Collaborate with internal clinical and claims teams.
• Ensure adherence to statutory turn-around times (TAT).
• Draft clear, compliant determination letters.
• Direct experience handling health plan complaints and familiarity with core administrative platforms are strongly preferred.

Qualifications

• High School Diploma or GED required; Associate or Bachelor’s degree in Healthcare Administration, Business, Communications, or a related field preferred.
• Minimum of 2–4 years of operational experience within a managed care organization (MCO), health plan, or Third-Party Administrator (TPA), with at least 1–2 years dedicated to health plan complaints, grievances, or appeals.
• Solid working knowledge of Commercial health insurance products, including Large Group and Individual & Family Plans (IFP/ACA/Exchange).
• Familiarity with federal and state appeal regulations, prompt-pay standards, grievance classification taxonomies, and external review procedures.
• Strong written communication skills, with proven ability to translate complex medical and benefits terminology into member-friendly explanations.
• Proven ability to work autonomously, prioritize competing deadlines, and maintain strict confidentiality (HIPAA compliance) in a home-office environment.

Requirements

• Manage an active pipeline of member and provider grievances, pre-service appeals, post-service claim appeals, and regulatory complaints from intake through resolution.
• Investigate underlying issues by reviewing plan documents (Evidence of Coverage, Summary of Benefits, Provider Manuals), claims history, medical records, billing records, and prior customer service contact logs.
• Serve as the liaison between members, providers, and internal departments to resolve issues effectively.
• Make appropriate outbound contact to members or providers to collect all relevant information to complete reviews.
• Coordinate with internal Harbor Health departments to evaluate disputed issues and ensure appropriate adjudication.
• Process grievances and appeals within statutory timeframes.
• Compose written correspondence in clear, plain language tailored to the member's literacy level.
• Maintain complete, audit-ready case files with all relevant documentation, rationales, internal notes, and correspondence logs.
• Prepare case summaries and documentation packets for Independent Review Organizations (IROs) or Independent Dispute Resolution (IDR) filings when cases escalate.
• Document every step of the investigation and resolution process inside the core case management system.
• Utilize health plan processing platforms to look up claims data, review call center customer service notes, verify enrollment, and track grievance statuses.
• Identify operational trends, root-cause billing/adjudication errors, or systemic member pain points and escalate them to leadership for process improvement.

Benefits

• Fully remote work environment
• Competitive salary and benefits package
• Generous PTO
• 10 paid holidays
• Medical, Dental, and Vision Insurance
• 401(k) Investment Plan
• Professional development and growth opportunities
• A transparent and unique culture
• Collaborative and dynamic work environment

Company Description

At Harbor Health, we're transforming healthcare in Texas through collaboration and innovation. We're seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you're ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!