Grievance & Appeals Resolution Specialist

Clever Care is a dynamic and rapidly expanding Medicare Advantage plan provider based in Southern California, recognized for its commitment to delivering innovative healthcare solutions to diverse communities. With an extraordinary year-over-year membership growth of 112 percent, Clever Care is transforming the healthcare landscape by blending Western medical practices with holistic Eastern therapies to better align with the cultural values and preferences of its members. This approach highlights the organization's dedication to accessibility, inclusion, and tailored healthcare services that address both medical and cultural needs. Clever Care operates as a forward-thinking company in the healthcare insurance sector, specifically servicing Medicare Advantage plans, and is headquartered in Los Angeles, supported by employees from the greater Los Angeles and Orange County areas.

The Appeals and Grievances Resolution Specialist position at Clever Care operates on a hybrid work schedule, requiring candidates to reside in either Los Angeles or Orange County. This role is critical in ensuring the integrity and efficiency of the grievances and appeals processes, which contribute to member satisfaction and regulatory compliance. The specialist is responsible for managing the intake, investigation, and resolution of member grievances, appeals, provider disputes, and complaints, ensuring all activities consistently adhere to standards such as CMS regulations, NCQA benchmarks, and relevant state and contractual rules. Beyond administrative responsibilities, this position demands analytical expertise to independently resolve non-clinical cases using sound judgment. It involves collaboration with clinical and operational teams to deliver timely and accurate resolutions.

The Resolution Specialist plays an essential role in maintaining compliance with CMS turnaround time requirements and preparing detailed documentation for internal and external audits. This includes supporting CMS Complaints Tracking Module (CTM) activities, ensuring all responses are comprehensive and submitted within regulated deadlines. Maintaining audit-ready case files is another vital aspect, as is identifying trends and root causes in the grievance and appeals data to inform quality improvement efforts and enhance Star Ratings performance.

Further duties include assisting the Member Services department during high-volume periods by handling overflow calls and participating in outbound campaigns, demonstrating the specialist’s versatile role within the organization. The position demands excellent written and verbal communication skills as well as the ability to manage multiple cases effectively in a fast-paced environment. Proficiency in Microsoft Office tools, particularly Word, Excel, and PowerPoint, and a typing speed of at least 40 words per minute are important technical skills for success in this role.

In summary, the Appeals and Grievances Resolution Specialist at Clever Care is a pivotal team member contributing to the organization’s mission of making healthcare accessible and culturally sensitive while meeting stringent industry standards. This opportunity offers the chance to be part of a mission-driven, innovative company where the specialist’s work directly impacts underserved communities and supports the continuous improvement of healthcare delivery. The position offers a competitive wage range from $26.00 to $32.00 per hour and requires the ability to perform in an office or remote setting with some travel as needed.