**Overview**
BroadPath is excited to announce that we are hiring **Work from Home Appeals and Grievance Specialists** . The Appeals and Grievance Specialist plays a key role in helping members navigate and understand their benefits related to Appeals, External Medical Review, and the Fair Hearing process. Acts as the first point of contact for members, providing support and information through both verbal and written communication throughout the resolution journey.
**Compensation Highlights:**
+ Base Pay: Up to $22 an hour
+ Pay Frequency: Weekly
**Schedule Highlights:**
+ Training Schedule: 2 weeks, Monday-Friday, 8:00 AM - 5:00 PM CST
+ Production Schedule: Monday-Friday, 8:00 AM - 5:00 PM CST, no weekends!
**Responsibilities**
_Responsibility A: Provides member support and advocacy_
+ Helps members understand their rights and responsibilities including the appeals process, External Medical Review and State Fair Hearing
+ Stands in as an advocate for members during appeals, External Medical Review and State Fair Hearings and gathers all required information for proper representation
+ Addresses complex issues with a proactive approach and delivers timely solutions while outlining the most effective path forward and clearly communicating next steps to all parties involved
+ Monitors real-time queues and adherence reports to maintain service levels and response expectations and manages real-time escalations as needed
+ Works collaboratively with Claims, Eligibility, Provider Relations, Business Operations and other Health Plan teams to resolve member and provider concerns
+ Translates member communications and documents between English and Spanish while ensuring the original message is accurately conveyed and provides interpretation to support communication between Spanish-speaking members and non-bilingual clinical staff while being mindful of cultural nuances and applying medical interpretation skills
+ Assists with referrals to Case Management, Service Coordination and Population Health programs when appropriate
_Responsibility B: Supports Appeals, External Medical Review (EMR) and State Fair Hearing processes_
+ Responds to internal system alerts and coordinates with other departments when needed to resolve identified issues
+ Builds strong working relationships within the department and across teams to support collaborative problem solving, workflow improvements and knowledge sharing
+ Initiates the EMR and State Fair Hearing process using the HHSC Intake Portal - Texas Integrated Eligibility Redesign System (TIERS)
+ Supports the Medical Director throughout the EMR and State Fair Hearing process
+ Leads internal Pre-Fair Hearing discussions
+ Oversees the EMR and State Fair Hearing program by entering required information into TIERS and tracking compliance with regulatory standards
+ Works with delegates to gather necessary documents for EMR and Fair Hearing requests and ensures required information is submitted to HHSC within mandated timeframes
+ Inputs EMR and Fair Hearing data into the Utilization Management system with accuracy and completeness per established guidelines
+ Provides data and information for internal and external reporting related to EMR and Fair Hearing activity
_Responsibility C: Participates in the Utilization Management process_
+ Delivers administrative support for the UM program by collecting member and provider information through phone, OnBase, CRM and secure provider portals and applies knowledge of ICD-10, CPT, HCPCS codes and medical terminology to ensure all information needed for clinical review is complete
+ Uses available tools and UM protocols to confirm member and provider details when evaluating prior authorization and appeal submissions
_Responsibility D: Participates in quality initiatives_
+ Supports leadership in identifying opportunities for process enhancements and service improvement and assists with creating and carrying out action plans
+ Takes part in department projects and committee work as assigned
+ Recognizes trends and workflow opportunities based on customer interactions that may call for changes to existing procedures or the creation of new processes
**Qualifications**
+ High school diploma or equivalent
+ 4+ years of foundational Utilization Management experience
+ General understanding of health plan operations, claims and eligibility systems, claims processing, and health care benefits
+ Familiarity with Texas Department of Insurance and HHSC rules for managing member complaints and appeals
+ Experience with managed care, Medicaid programs, call center support tools, customer service practices, and basic computer skills
+ Ability to interact effectively with the public, maintain a customer-focused approach, and work well independently or as part of a team
+ Strong interpersonal skills and professional phone etiquette
+ Clear and effective verbal communication skills
+ Active listening skills
+ Understanding of medical terminology
+ Strong problem-solving abilities and ability to handle multiple tasks simultaneously
+ High attention to detail
**Preferred:**
+ 2+ years of direct experience with UM Prior Authorizations, Appeals, Fair Hearings and External Medical Review
+ Community Health Worker (CHW) certification, Texas Department of State Health Services
+ Background in benefits, claims processing, or membership
**Diversity Statement**
_At BroadPath, diversity is our strength. We embrace individuals from all backgrounds, experiences, and perspectives. We foster an inclusive environment where everyone feels valued and empowered. Join us and be part of a team that celebrates diversity and drives innovation!_
_Equal Employment Opportunity/Disability/Veterans_
_If you need accommodation due to a disability, please email us at_
[email protected]_ _. This information will be held in confidence and used only to determine an appropriate accommodation for the application process._
_BroadPath is an Equal Opportunity Employer. We do not discriminate against our applicants because of race, color, religion, sex (including gender identity, sexual orientation, and pregnancy), national origin, age, disability, veteran status, genetic information, or any other status protected by applicable law._
_Compensation: BroadPath has an effective process for assessing market data and establishing ranges to ensure we remain competitive. You are paid within the salary range based on your experience and market data of the position. The actual salary for this role may vary by location._