Specialist, Admin Complaints, Grievances & Appeals

Specialist, Admin Complaints, Grievances & Appeals

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 plan's 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.

Pay Transparency : The hourly rate for this role is : $22.00 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 :

Bonus Points :