Grievance & Appeals Resolution Specialist

This position operates on a hybrid work schedule. Candidate must reside in Los Angeles or Orange County.

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California's fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We?

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members' culture and values.

Why Join Us?

We're on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

The Appeals & Grievances Resolution Specialist supports the intake, investigation, and resolution of member grievances, appeals, provider disputes, and complaints in accordance with CMS regulations, NCQA standards, and applicable state and contractual requirements.

This role independently manages assigned cases within established guidelines, applies sound analytical judgment to resolve non-clinical matters, collaborates with clinical and operational partners, and ensures timely, accurate, and compliant case resolution. The Resolution Specialist is accountable for meeting CMS turnaround time requirements, maintaining audit-ready documentation, supporting CMS Complaints Tracking Module (CTM) activities, and contributing to quality improvement and Star Ratings performance through effective trend identification and member-centered communication.

The Appeals & Grievances Resolution Specialist may also assist the Member Services department with overflow calls and outbound campaigns as business needs require.

Essential Functions & Job Responsibilities

• Intake, investigate, document, and resolve member grievances, appeals, and provider disputes in compliance with CMS, NCQA, state, and contractual requirements.
• Ensure cases are processed within required turnaround times and accurately tracked through resolution.
• Apply sound, fact-based decision-making to resolve non-clinical complaints and appeals.
• Communicate with members and providers to obtain additional information, explain decisions, and provide clear written and verbal case outcomes.
• Support intake, investigation, and resolution of CMS Complaints Tracking Module (CTM) cases, ensuring timely, accurate, and compliant responses.
• Prepare appeal summaries, determination letters, and supporting documentation for internal review, CMS universes, audits, and oversight entities.
• Coordinate with Medical Management, Claims, Provider Relations, Compliance, and other departments to facilitate timely case resolution.
• Maintain accurate, complete, and compliant documentation in case tracking systems.
• Identify and analyze trends and root causes in grievances, appeals, and complaints, and report findings to leadership to support quality improvement initiatives and reduce repeat issues.
• Maintain audit-ready case files and support CMS audit and universe submission activities, including data validation, case review, and response to regulatory requests.
• Perform quality audits and monitoring activities; report findings and recommend corrective actions.
• Assist with development and maintenance of desk-level procedures, job aids, and training materials.
• Support HEDIS-related activities as assigned, including data entry, provider outreach, and claims research.
• Assist Member Services with overflow calls and outbound campaigns during high-volume periods, as needed.
• Prepare reports and summaries for internal committees, compliance meetings, and leadership review.
• Represent the organization professionally and compassionately when interacting with members, providers, and internal partners.