Specialist, Admin Complaints, Grievances & Appeals

Hi were Oscar. Were hiring a Specialist Admin Complaints Grievances & Appeals to join our Complaints Grievances & Appeals 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 ourselvesone that behaves like a doctor in the family.

About the role:

You will be responsible for the comprehensive management and resolution of complex administrative member and/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 plans governing bodies while championing member satisfaction and retention.

You will report into the Associate Director Member & Provider Escalations.

Work Location: This is a remote position open to candidates who reside in: Arizona; Florida; Georgia; or Texas. While your daily work will be completed from your home office occasional travel may be required for team meetings and company events. #LI-Remote

Pay Transparency: The hourly rate for this role is: $24.00 per hour. You are also eligible for employee benefits and monthly vacation accrual at a rate of 15 days per year.

Responsibilities:

• Follow established workflows to acknowledge log and perform initial triage on complex or escalated administrative grievances from members and/or providers
• Conduct thorough multi-faceted investigations by gathering and analyzing internal data call logs correspondence etc.
• Use workflows to reconstruct complex event timelines involving prior authorizations claims processing and system-based adjudication edits to accurately determine the root cause of member and/or provider issues.
• Liaise 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 utilizing established workflows.
• Escalate the issue to leadership for further guidance on resolution strategy as needed
• Draft clear accurate complete resolution letters ensuring all required regulatory elements are included
• Maintain meticulous and comprehensive case files in the case management system to ensure a clear and complete audit trail for each case
• Monitor and manage case timelines to ensure strict adherence to all federal and state mandated deadlines
• Compliance with all applicable laws and regulations
• Other duties as assigned

Requirements:

• 1 years of professional experience in a regulated industry such as healthcare insurance
• 1 years of experience independently managing a demanding caseload with multi-step workflows from initial intake through investigation resolution and final documentation while meeting competing priorities.
• 1 years of experience with directly managing escalated customer member or provider cases
• 1 years of experience with drafting and issuing formal written communication to member or providers
• 1 years of experience working in a highly structured workflow driven environment

Bonus points:

• Bilingual in Spanish (reading and writing)
• Bachelors degree
• Experience in health care administration.
• Involvement in departmental or cross-functional process improvement or quality initiatives.

This is an authentic Oscar Health job opportunity. Learn more about how you can safeguard yourself from recruitment fraud here .

At Oscar being an Equal Opportunity Employer means more than upholding discrimination-free hiring practices. It means that we cultivate an environment where people can be their most authentic selves and find both belonging and support. Were on a mission to change health care -- an experience made whole by our unique backgrounds and perspectives.

Pay Transparency: Final offer amounts within the base pay set forth above are determined by factors including your relevant skills education and experience. Full-time employees are eligible for benefits including: medical dental and vision benefits 11 paid holidays paid sick time paid parental leave 401(k) plan participation life and disability insurance and paid wellness time and reimbursements.

Artificial Intelligence (AI): Our AI Guidelines outline the acceptable use of artificial intelligence for candidates and detail how we use AI to support our recruiting efforts.

Reasonable Accommodation: Oscar applicants are considered solely based on their qualifications without regard to applicants disability or need for accommodation. Any Oscar applicant who requires reasonable accommodations during the application process should contact the Oscar Benefits Team () to make the need for an accommodation known.

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Required Experience:

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