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Clever Care Health Plan · 6 hours ago

Grievance & Appeals Resolution Specialist

Huntington Beach Office - Huntington Beach, CA 92647

Full-time

Hybrid

Entry, Mid Level

$25/hr - $29/hr

2+ years exp

Clever Care Health Plan is one of Southern California’s fastest-growing Medicare Advantage plans, dedicated to making healthcare accessible for underserved communities. The Appeals & Grievances Resolution Specialist will support the intake, investigation, and resolution of member grievances and appeals, ensuring compliance with CMS regulations and maintaining quality documentation.

Health Care

Responsibilities

Intake, investigate, document, and resolve member grievances, appeals, and provider disputes in compliance with CMS, NCQA, state, and contractual requirements

Ensure cases are processed within required turnaround times and accurately tracked through resolution

Apply sound, fact-based decision-making to resolve non-clinical complaints and appeals

Communicate with members and providers to obtain additional information, explain decisions, and provide clear written and verbal case outcomes

Support intake, investigation, and resolution of CMS Complaints Tracking Module (CTM) cases, ensuring timely, accurate, and compliant responses

Prepare appeal summaries, determination letters, and supporting documentation for internal review, CMS universes, audits, and oversight entities

Coordinate with Medical Management, Claims, Provider Relations, Compliance, and other departments to facilitate timely case resolution

Maintain accurate, complete, and compliant documentation in case tracking systems

Identify and analyze trends and root causes in grievances, appeals, and complaints, and report findings to leadership to support quality improvement initiatives and reduce repeat issues

Maintain audit-ready case files and support CMS audit and universe submission activities, including data validation, case review, and response to regulatory requests

Perform quality audits and monitoring activities; report findings and recommend corrective actions

Assist with development and maintenance of desk-level procedures, job aids, and training materials

Support HEDIS-related activities as assigned, including data entry, provider outreach, and claims research

Assist Member Services with overflow calls and outbound campaigns during high-volume periods, as needed

Prepare reports and summaries for internal committees, compliance meetings, and leadership review

Represent the organization professionally and compassionately when interacting with members, providers, and internal partners

Qualification

Medicare Advantage experienceCMS regulations knowledgeCase tracking systemsAnalytical skillsMicrosoft Office proficiencyMedical coding knowledgeBilingual KoreanBilingual VietnameseBilingual MandarinCommunication skills