Customer Support Specialist

Role overview

This remote Customer Support Specialist position supports appeals and grievances operations for a client team. The work is focused on handling lower-complexity matters first, building expertise in specialty-level appeals and grievance processes, and helping drive favorable outcomes for members. Although the role is remote, candidates must live in California.

What you'll do

• Handle simpler appeals and grievance cases while developing capability in specialty-level work, with the goal of improving member outcomes.
• Help identify, review, and resolve administrative complaints and straightforward appeals in line with CMS, DHCS, DMHC, MRMIB, and NCQA standards.
• Receive complaints, acknowledge them, prepare case documentation, and direct matters to the correct internal teams or external partners for investigation and resolution.
• Use sound independent judgment to manage assigned cases accurately and within required timelines.
• Escalate complicated questions or issues to leadership when needed.
• Contribute in team meetings and share practical improvement ideas based on what you observe.
• Take on additional related duties as assigned.

Requirements

• High school diploma or high school equivalency certificate required.
• Associate degree required.
• At least 1 year of experience in managed care, including work with Medicare, Medi-Cal, or other state-sponsored programs.
• Experience working to firm deadlines and applying regulations correctly.
• Strong organization, attention to detail, and the ability to exercise independent judgment.
• Conflict resolution and persuasion skills.
• Effective communication and presentation abilities, with the confidence to collaborate across internal departments, service areas, plan partners, provider groups, and outside agencies.
• Proficiency with Microsoft Word, Outlook, and Excel.
• Ability to maintain confidentiality while delivering professional customer service.
• Comfort working under tight deadlines and strict regulatory timelines.
• Strong analytical, verbal, written, and presentation skills.
• Medical terminology knowledge and strong advocacy experience preferred.
• Familiarity with DHCS, NCQA, CMS, and DMHC guidelines is preferred.

Additional information

This position is part of a pay range structure based on relevant education, qualifications, certifications, experience, skills, seniority, location, performance, union agreement, and business needs. The employer notes that the stated range may change in the future.

Benefits offered to eligible employees include medical, dental, and vision coverage, HSA, FSA, 401(k), and life, disability, and ADD insurance. Salaried employees receive paid time off. Hourly employees are generally not eligible for PTO unless required by law, though hourly employees on a Service Contract Act project may receive paid sick leave.

Compensation is not considered earned until it is vested and payable. The employer may modify compensation details at its discretion, consistent with applicable law.

This role does not include bonuses, incentives, or commissions.

The employer is an equal opportunity and affirmative action employer. All qualified candidates are considered without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability.

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