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Sidecar Health is transforming health insurance by making excellent healthcare affordable and accessible. As an Appeals and Grievances Specialist, you will own the end-to-end handling of member and provider appeals and grievances, investigating cases, coordinating with internal teams, and delivering clear, well-reasoned resolutions within regulatory timelines.
This role sits at the intersection of advocacy, compliance, and operations. You'll work directly with members and providers who need someone to take their concerns seriously, dig into the details, and provide trustworthy answers. You'll report to the Director of Quality and Continuous Improvement and collaborate closely with QA, Claims, Clinical, and Provider Relations teams to reach fair, well-documented outcomes.
Key responsibilities include:
- Intake, triage, and manage a caseload of member and provider appeals and grievances from submission through resolution
- Investigate each case thoroughly, reviewing claims history, benefit determinations, clinical documentation, and prior correspondence
- Apply plan documents, state and federal regulations, and company policy to reach accurate, well-documented determinations
- Draft clear, compliant resolution letters and member/provider communications in Sidecar Health's brand voice
- Track all cases and deadlines to ensure compliance with state and federal turnaround time requirements
- Coordinate with Claims, Clinical, Provider Relations, and Legal teams to gather information and resolve complex cases
- Contribute to process improvements and identify trends in appeals and grievances to enhance member and provider experience
This is an individual contributor role requiring strong attention to detail, regulatory knowledge, and the ability to communicate complex healthcare and insurance concepts clearly to diverse audiences.
