Grievance & Appeals Specialist

Job Summary

WPS Health Solutions New is seeking a Grievance & Appeals Specialist in Fitchburg, Dane County, US. The role involves reviewing and resolving member and provider grievances, complaints, appeals, and claim disputes for Commercial and Medicare health plans.

Key Responsibilities

• Receive, investigate, and adjudicate member and provider grievances, complaints, and appeals in accordance with contractual and regulatory guidelines.
• Analyze provider claim disputes, coordinate documentation, and communicate decisions to stakeholders.
• Maintain accurate case records in the claims management system and ensure timely closure of all cases.
• Collaborate with internal teams—including Customer Service, Clinical, Legal, and Compliance—to gather information and resolve issues efficiently.
• Prepare detailed reports and metrics on grievance trends, appeal outcomes, and compliance performance.
• Stay current on federal and state regulations (e.g., HIPAA, CMS rules) and ensure all actions meet compliance standards.
• Provide education and guidance to members and providers on grievance and appeal processes.

Qualifications

• Bachelor’s degree in Health Administration, Business, or related field (or equivalent experience).
• 2+ years’ experience handling health‑plan grievances, appeals, or provider claim disputes.
• Strong analytical and problem‑solving skills with attention to detail.
• Excellent written and verbal communication; ability to interact professionally with members, providers, and internal partners.
• Proficiency with case‑management software and Microsoft Office suite.
• Knowledge of Medicare, Commercial health‑plan regulations, and compliance requirements.

Compensation & Benefits

Base salary: $80,291.64 annually. Competitive benefits package includes health, dental, vision, 401(k) match, paid time off, and professional development opportunities.

Frequently Asked Questions

What types of cases will I handle as a Grievance & Appeals Specialist?

You will review and resolve member grievances, provider complaints, appeals, and claim disputes for both Commercial and Medicare health‑plan products.

What qualifications are required for this position?

A bachelor’s degree or equivalent experience, at least two years handling health‑plan grievances or appeals, strong analytical skills, and knowledge of relevant regulations.

What is the salary for this role?

The position offers a fixed annual salary of $80,291.64 plus a comprehensive benefits package.