Specialist, Admin Complaints, Grievances & Appeals

Hi, we're Oscar. We're hiring a Specialist, Admin Complaints, Grievances & Appeals to join our CGA & MPCT team.

Oscar is the first health insurance company built around a full stack technology platform and a relentless focus on serving our members. We started Oscar in 2012 to create the kind of health insurance company we would want for ourselves—one that behaves like a doctor in the family.

About the role:

The CGA Liaison is responsible for the comprehensive management and resolution of complex administrative member or provider grievances and appeals. You will serve as a subject matter expert on non-clinical case resolution, focusing on sensitive member issues such as 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.

You will report into our CGA Team Lead.

Work Location: This is a remote position, open to candidates who reside in: Arizona, Texas, Florida or Georgia. You will be fully remote; however, our approach to work may adapt over time. Future models could potentially involve a hybrid presence at the hub office associated with your metro area.

Pay Transparency: The base pay for this role in the states of California, Connecticut, New Jersey, New York, and Washington is: $46,368- $60,858 per year. The base pay for this role in all other locations is: $41,731 - $54,772 per year. You are also eligible for employee benefits, monthly vacation accrual at a rate of 15 days per year.

Responsibilities:

• Follow established workflows to log initial assessment on complex or escalated administrative grievances from members or providers.
• Conduct, multi-faceted investigations by gathering and analyzing internal data, call logs, and correspondence.
• Use workflows to reconstruct complex event timelines involving prior authorizations, claims processing, and system-based adjudication edits to determine the cause of member or provider issues.
• Collaborate with internal departments, such as Member Services, Eligibility & Benefits, and Claims, to obtain necessary information for complete case resolution.
• Based on investigative findings, determine a resolution strategy that is both fair and compliant with company and regulatory guidelines, using established workflows.
• Escalate the issue to leadership for further guidance on resolution strategy.
• Draft clear, accurate, complete resolution letters, including all required regulatory elements.
• Maintain meticulous and comprehensive case files in the case management system to provide a clear and complete audit trail for each case.
• Manage case timelines to ensure strict adherence to all federal and state mandated deadlines.
• Compliance with all applicable laws and regulations.
• Other responsibilities as assigned.

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 with directly managing escalated customer, member or provider cases.
• 1+ years of experience drafting and issuing formal written communication to member and providers.
• 1+ years of experience working in a structured, workflow-driven, environment.

Bonus points:

• Bachelor's degree.
• Experience in health care administration.
• Involvement in departmental or process improvement or quality programs.
• Bilingual proficiency in English and Spanish.