Appeals and Grievances Specialist

Responsibilities

• Intake, triage, and manage a caseload of member and provider appeals and grievances
• Investigate cases by reviewing claims history, benefit determinations, and clinical documentation
• Apply plan documents and state/federal regulations to reach accurate determinations
• Draft clear, compliant resolution letters and communications
• Track cases and deadlines to ensure regulatory compliance
• Coordinate with Claims, Clinical, Provider Relations, and Legal teams
• Identify escalation risks and flag process patterns to leadership
• Maintain accurate records in the case management system

Requirements

• Bachelor's degree in healthcare administration, business, public health, or related field
• 3+ years of experience in appeals and grievances, claims adjudication, or health insurance operations
• Working knowledge of health insurance regulatory requirements (state DOI, ERISA, ACA)
• Strong analytical skills for reading claims data and clinical notes
• Excellent written communication skills
• Ability to manage a caseload independently and meet hard deadlines
• Member-first mindset with attention to compliance

Preferred Qualifications

• Experience with Genesys Cloud, Salesforce, or similar CRM platforms
• Familiarity with Medicare Advantage or ACA marketplace appeals
• Experience in a fast-growing or start-up health insurance environment

Benefits

• Competitive salary, bonus opportunity, and equity package
• Comprehensive Medical, Dental, and Vision benefits
• 401k retirement plan
• Paid vacation and company holidays

About the Company

Sidecar Health is redefining health insurance with a mission to make excellent healthcare affordable and accessible for everyone.