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Salary: USD 41,731 - 54,772 / annual
Oscar Health is seeking a Specialist, Administrative Complaints, Grievances & Appeals to join the CGA & MPCT team. This role is fully remote and open to candidates residing in Arizona, Texas, Florida, or Georgia.
You will be responsible for the comprehensive management and resolution of complex administrative member and provider grievances and appeals. As a subject matter expert on non-clinical case resolution, you will focus on sensitive member issues including claims concerns, access barriers, benefits concerns, and complex service inquiries. You will drive the resolution process to meet regulatory standards set by the health plan's governing bodies while promoting member satisfaction and retention.
Key responsibilities include:
- Logging initial assessments on complex or escalated administrative grievances from members or providers using established workflows
- Conducting multi-faceted investigations by gathering and analyzing internal data, call logs, and correspondence
- Reconstructing complex event timelines involving prior authorizations, claims processing, and system-based adjudication edits to determine root causes
- Collaborating with internal departments such as Member Services, Eligibility & Benefits, and Claims to obtain necessary information
- Determining fair and compliant resolution strategies based on investigative findings
- Escalating issues to leadership for guidance on resolution strategy when needed
- Drafting clear, accurate, and complete resolution letters that include all required regulatory elements
- Maintaining meticulous case files in the case management system to provide clear audit trails
- Managing case timelines to ensure strict adherence to federal and state mandated deadlines
- Ensuring compliance with all applicable laws and regulations
You will report to the CGA Team Lead. While this is currently a fully remote position, Oscar's approach to work may adapt over time, and future models could potentially involve hybrid presence at the hub office associated with your metro area.
Requirements:
- 1+ years of professional experience in a regulated industry such as healthcare, insurance, or finance
- 1+ years of experience independently managing a demanding caseload with multi-step workflows, from initial intake through investigation, resolution, and final documentation
- 1+ years of experience directly managing escalated customer, member, or provider cases
- 1+ years of experience drafting and issuing formal written communication to members and providers
- 1+ years of experience working in a structured, workflow-driven environment
Bonus qualifications:
- Bachelor's degree
- Experience in healthcare administration
- Involvement in departmental or process improvement or quality programs
- Bilingual proficiency in English and Spanish
