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Appeals Grievances Jobs (NOW HIRING)

MedImpact

Appeals & Grievances Coordinator II

San Diego, CA · On-site

$25.50 - $31.19/hr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

The Appeals & Grievances Coordinator II serves as a key member of the A&G team, processing appeal and grievance requests in accordance with established standards for accuracy, timeliness ...

MedImpact

Appeals & Grievances Coordinator II

San Diego, CA · On-site +1

$25.50 - $31.19/hr

  • Medical

  • Dental

  • Vision

  • Life

  • Retirement

  • PTO

The Appeals & Grievances Coordinator II serves as a key member of the A&G team, processing appeal and grievance requests in accordance with established standards for accuracy, timeliness ...

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Healthcare Appeals and Grievances Coordinator

Columbus, OH · On-site

$23/hr

  • Medical

  • Dental

  • Vision

Appeals & Grievances Coordinator Location: Remote (Must reside in Ohio; candidates located near Columbus are highly preferred. Training may take place at the Easton office.) Pay: $23.00/hour Schedule:

Curana Health, Inc.

Curana Health is seeking an experienced Appeals & Grievances Specialist to join our growing team. In this role, you will investigate and resolve member and provider appeals and grievances, ensuring ...

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How much do appeals grievances jobs pay per year?

As of Aug 14, 2026, the average yearly pay for appeals grievances in the United States is $86,480.00, according to ZipRecruiter salary data. Most workers in this role earn between $66,500.00 and $98,500.00 per year, depending on experience, location, and employer.

What are the typical challenges faced in an appeals grievances role, and how can they be effectively managed?

One common challenge in this role is managing a high volume of complex cases while adhering to strict regulatory deadlines. Appeals Grievances professionals often navigate sensitive situations involving dissatisfied members or providers, requiring strong problem-solving skills and composure under pressure. Collaboration with medical professionals, legal staff, and other departments is frequent to ensure cases are resolved thoroughly and fairly. Staying organized, maintaining up-to-date knowledge of changing regulations, and prioritizing effective communication are key to successfully meeting these demands and maintaining quality outcomes.

What does an appeals grievances job involve?

An Appeals and Grievances job involves reviewing, processing, and resolving complaints or appeals from customers, typically in healthcare or insurance industries. Professionals in this role assess cases to ensure compliance with regulations, company policies, and contractual obligations. They communicate with customers, providers, and internal departments to investigate issues and provide fair resolutions. Strong analytical, communication, and problem-solving skills are essential for success in this role.

What are the key skills and qualifications needed to thrive in the appeals grievances position?

To thrive as an Appeals Grievances professional, you need a detailed understanding of claims processing, knowledge of healthcare policies and regulations, and strong analytical skills, often supported by a degree in healthcare administration or a related field. Familiarity with case management systems, Microsoft Office tools, and sometimes specialized software like Facets or QNXT is essential. Excellent written and verbal communication, attention to detail, and the ability to handle sensitive situations with empathy are standout soft skills. These competencies ensure accurate resolution of appeals and grievances, regulatory compliance, and positive member experiences.

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Appeals Grievances jobs near you
Infographic showing various Appeals Grievances job openings in the United States as of August 2026, with employment types broken down into 91% Full Time, 7% Part Time, and 2% Contract. Highlights an 80% Physical, 7% Hybrid, and 13% Remote job distribution, with an average salary of $86,480 per year, or $41.6 per hour.

Appeals & Grievances Nurse

Western Health Advantage

Sacramento, CA • On-site

$95K - $115K/yr

Full-time

Re-posted 21 days ago

Job description

Appeals & Grievances Nurse (RN)
Western Health Advantage
Location: Sacramento, CA (Hybrid)
Job Type: Full-Time, Exempt
Salary: $95,000-$115,000 annually
Travel: Occasional travel required
"Purpose that inspires. Impact that improves lives. Join us in building healthier communities."
Western Health Advantage
Join Our Team
Western Health Advantage (WHA) is seeking an experienced Appeals & Grievances Nurse (RN) to join our Utilization Management team. This role is ideal for a registered nurse with managed care experience who is passionate about ensuring members receive timely, clinically sound, and compliant reviews of appeals and grievances.
Reporting to the Utilization Operations Director, you will collaborate with Medical Directors, Clinical Pharmacists, Appeals & Grievances staff, and contracted provider groups to evaluate complex cases, ensure regulatory compliance, and support exceptional member outcomes.
What You'll Do
As the Appeals & Grievances Nurse, you will:
  • Review medical necessity appeals and grievances requiring clinical evaluation.
  • Research, analyze, and prepare complex appeal cases involving new technology, experimental treatments, transplants, and other specialized services.
  • Determine clinical urgency and provide guidance to the Appeals & Grievances team.
  • Prepare clinical summaries and recommendations for Medical Director review and Appeal Review Meetings.
  • Draft clinical resolution letters for upheld medical necessity determinations.
  • Partner with contracted Medical Groups, hospitals, and providers to coordinate member care and facilitate smooth transitions across the continuum of care.
  • Collaborate with internal departments including Quality Management, Care Management, Member Services, Sales, Marketing, and Wellness on clinical initiatives and special projects.
  • Assist with referrals to Case Management, Disease Management, and Behavioral Health services.
  • Provide care coordination and support for members receiving transgender surgery services.
  • Maintain and update utilization management reference materials, including prior authorization and DME benefit resources.
  • Support regulatory readiness by participating in DMHC, CMS, and NCQA audits, accreditation activities, RFP responses, and Independent Medical Review submissions.
  • Participate in conference calls with regulatory agencies and provide clinical expertise on appeals and grievance cases.
  • Promote compliance with regulatory requirements while ensuring timely, accurate, and member-focused case resolutions.
What You'll Bring
Required Qualifications
  • Bachelor's degree in Nursing (BSN).
  • Active and unrestricted California Registered Nurse (RN) license.
  • 3 years' experience in utilization/case management, discharge planning and/or appeals & grievances in a managed care environment, with increased responsibilities.
  • Strong clinical assessment, critical thinking, and analytical skills.
  • Excellent written and verbal communication skills.
  • Intermediate Microsoft Office skills, including Excel and Word.
  • Certification in Utilization Management (CPHM, CMCN, or equivalent), Quality Management, or Certified Case Manager (CCM).
  • Knowledge of California Department of Managed Health Care (DMHC) regulations.
  • Familiarity with CMS Medicare regulations.
  • Experience supporting NCQA accreditation activities.
  • Experience preparing regulatory responses, audits, or quality improvement initiatives.
Why Join Western Health Advantage?
At WHA, you'll have the opportunity to make a meaningful impact on the quality and accessibility of healthcare for our members. You'll collaborate with experienced clinical leaders in a supportive, mission-driven environment that values clinical excellence, regulatory compliance, and continuous improvement.

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