Appeals & Grievances Specialist II
Western Health Advantage, Sacramento, California, United States, 95828
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.
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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.
#J-18808-Ljbffr