Appeals Coordinator

About OpTech

OpTech is a woman-owned organization that encourages new ideas, supports employee development, and stands behind its team. The company offers health and dental coverage, training opportunities, flexible remote work, growth pathways, a 401(k), and competitive compensation.

Role Summary

As a Member Resolution Specialist focused on Appeals & Grievances, you will act as an important advocate for members by reviewing, investigating, and resolving appeals and complaints with accuracy, empathy, and compliance. You will gather key details, perform in-depth research, and prepare clear, well-supported responses that meet regulatory and accreditation expectations.

In this position, you will be a primary contact for members, helping clarify concerns, collect necessary information, and ensure each matter is fully reviewed before a final decision is issued. Your efforts will help deliver a fair, compliant outcome and support a strong member experience for complex healthcare-related cases.

This position calls for strong analysis, close attention to detail, and the ability to manage a busy workload in a fast-moving environment while staying professional and compassionate.

Key Responsibilities

• Examine, assess, and close member appeals and grievances in line with regulatory and compliance requirements.
• Research each case thoroughly to support accurate resolution.
• Speak with members to obtain missing details and explain outcomes in a clear, professional manner.
• Review health plan policies, contract terms, and applicable regulatory rules.
• Record case notes and findings, and ensure every matter is resolved accurately and on time.
• Work within established processes to maintain quality and consistency.

Requirements

• High School Diploma or GED is required; a bachelor’s degree in English, Communications, Healthcare, or a related subject is preferred.
• At least 2 years of customer service experience is required.
• At least 2 years of health insurance experience is preferred, including exposure to Medicare/CMS and state or federal regulations.
• Strong business writing ability, including experience preparing formal letters or member-facing communications.
• Capability to analyze information, investigate concerns, and reach sound conclusions.
• Strong multitasking skills and the ability to perform well in a high-volume, deadline-focused setting.
• Comfort using computers and quick to learn new systems.
• Preferred background includes grievance and appeals work in a health plan or payer environment.
• Experience reviewing claims and understanding case outcomes, such as grievance, appeal, or organizational determination.
• Healthcare-related education or degree is preferred.
• Strong Microsoft Office skills, including Excel, PDF handling, and data entry/navigation.
• Experience supporting member or provider communications in a regulated setting is preferred.

Additional Information

Applications may be supported by recruiting technologies, including AI-assisted tools, for sourcing, matching, communication, and evaluation.

OpTech is an equal opportunity employer and provides consideration to all qualified applicants without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, pregnancy, parental status, disability, age, veteran status, or other protected characteristics under applicable federal, state, or local law.