Department: Appeals & Grievances
Status: Full-Time, Non-Exempt
Location: Onsite Sacramento/Hybrid 
Travel: None
Salary: $25.00 -$27.00 per hour

"Our purpose is strong, our impact is lasting, join us on the journey"
Western Health Advantage

Ensure Fair, Compliant, and Member-Focused Resolutions

Western Health Advantage is seeking a detail-oriented and experienced Appeals & Grievances Specialist II to support the timely and compliant processing of member appeals and grievances. In this fast-paced role, you will conduct comprehensive case reviews, ensure adherence to DMHC and NCQA regulatory standards, and collaborate with internal and external stakeholders to facilitate fair and accurate determinations.

This position is ideal for a healthcare professional who thrives in structured, regulatory environments, enjoys investigative case work, and is committed to protecting member rights while ensuring compliance and quality outcomes.

What You’ll Do

As an Appeals & Grievances Specialist II, you will manage and review complex cases while ensuring regulatory timeframes and documentation standards are met. Your responsibilities will include:

• Reviewing cases escalated from prior levels to ensure accurate classification, complete documentation, and appropriate categorization

• Providing accurate and timely written and verbal communication to members, providers, medical groups, brokers, delegated entities, and internal departments

• Confirming that requests have been routed to the appropriate entities and following up on missing responses

• Requesting and evaluating relevant documentation, medical records, and supporting information to ensure sufficient data for Plan determinations

• Maintaining thorough and accurate documentation of all outreach, communications, and case activities

• Identifying urgent matters or potential quality issues and promptly triaging cases to clinical staff or next-level support

• Preparing and organizing comprehensive case files, including medical records and written summaries for review

• Writing non-clinical case summaries and supporting administrative benefit/coverage dispute reviews

• Assisting with resolution letters based on benefit guidelines and/or medical necessity determinations, including member education

• Collaborating closely with A&G nurses to prepare cases for Appeal Review Meetings

• Identifying escalated matters and effectively communicating next steps

• Reporting emerging trends or recurring issues identified during case reviews

• Participating in process improvement initiatives and development of desktop guidelines

• Supporting team members with increased responsibilities and assisting in training new staff when requested

• Maintaining external contact lists and contracted counterparts for appeals and grievances

• Performing additional duties and special projects as assigned
   

  What We’re Looking For

  We’re seeking a healthcare professional with strong analytical skills, regulatory awareness, and the ability to manage complex cases with accuracy and professionalism.

  Required Qualifications

• High School Diploma or equivalent

• Minimum of 3 years of experience in a similar role with progressively increasing responsibilities

• Preferred Qualifications

• Experience with claims adjudication, referrals, and authorizations

• Previous experience working in the healthcare industry, particularly within an HMO environment

• Knowledge of medical terminology and the ability to clearly explain it to others

• Intermediate computer skills, including Microsoft Word and Excel, email, databases, and spreadsheets

• Strong written and verbal communication skills

• Ability to read, write, speak, and understand the primary language(s) used in the workplace

Why Join Western Health Advantage?

At Western Health Advantage, our Appeals & Grievances team plays a critical role in safeguarding member rights and ensuring regulatory compliance. As an Appeals & Grievances Specialist II, you’ll contribute to fair, timely, and thorough case resolution while collaborating across departments to uphold quality and accountability.

Physical Requirements

This role is primarily office-based. While performing job duties, the employee may occasionally stand, walk, sit, reach, or use hands to handle objects. The employee may occasionally lift or move up to 10 pounds. Reasonable accommodations may be made to enable individuals with disabilities to perform essential job functions.

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law.

Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.