Grievance Specialist

Health Plan Grievance & Appeals Specialist

Location: Portland, ME — Hybrid, approximately 1 day onsite per week

Schedule: Monday–Friday, 8:00 AM–5:00 PM

Pay: $30–$39/hour

About The Role

Our client is seeking a Health Plan Grievance & Appeals Specialist to join their health plan operations team. This position is responsible for reviewing and resolving member concerns from start to finish, including intake, research, investigation, documentation, and communication of the final outcome.

The ideal candidate will have hands-on experience within a health insurance or managed care environment, with a strong understanding of claims processing, health plan benefits, and grievances and/or appeals. This is a great opportunity for someone who enjoys investigative work, problem-solving, and helping resolve complex member issues while ensuring cases are handled accurately and within required regulatory timelines.

What You'll Do

• Manage member grievances from initial intake through investigation and final resolution.
• Review complaints to determine the appropriate classification, priority, and next steps.
• Research claims, benefits, authorizations, provider information, and other health plan records to understand the circumstances surrounding each case.
• Conduct thorough investigations and use independent judgment to determine appropriate resolutions.
• Identify when claims require correction or reprocessing based on plan benefits, policies, and the findings of the investigation.
• Gather information from members, providers, billing offices, internal departments, and other relevant sources.
• Prepare clear and accurate written correspondence related to case acknowledgments, resolutions, requests for information, and other required communications.
• Communicate with members and providers by phone and in writing regarding the status and resolution of concerns.
• Maintain detailed and accurate documentation throughout the grievance process.
• Manage multiple cases and work queues while meeting established turnaround times and regulatory deadlines.
• Partner with internal teams, including claims, clinical, provider, compliance, and other operational departments, to resolve complex issues.
• Assist with appeals coverage and other related activities as needed.
• Support internal and external audits by providing requested case documentation and information.
• Identify recurring issues or trends and bring potential process improvements or training opportunities to leadership.
• Help ensure grievance activities and documentation meet applicable privacy, HIPAA, regulatory, and organizational requirements.
• Serve as a resource to internal teams on grievance processes and health plan requirements.
  
  

What We're Looking For

• Bachelor's degree preferred; equivalent relevant experience will be considered.
• 3 years of experience in a health plan, managed care, health insurance, or similar environment.
• Previous experience working with grievances and/or appeals is required.
• Strong knowledge of claims processing and health plan benefits.
• Experience researching and resolving complex member or customer issues.
• Strong analytical and investigative skills with excellent attention to detail.
• Ability to interpret policies, benefits, claims information, and supporting documentation to determine appropriate resolutions.
• Excellent written and verbal communication skills.
• Strong customer service and interpersonal skills, particularly when working with sensitive or escalated concerns.
• Ability to manage multiple cases, priorities, and deadlines independently.
• Proficiency with Microsoft Office, particularly Word and Excel.
• Comfortable making decisions independently and exercising sound judgment within established guidelines.
  
  

Interested? Questions? Send all resumes and questions to Maresa at mscordino@naglergroup.com

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