Grievance & Appeals Claims Specialist - Managed Care Administration

We are recruiting for a mission-driven Grievance & Appeals Claims Specialist - Denver Health Medical Plan (Must Live in Colorado. Weekly On Site Requirement.) to join our team!

We're with you for life’s journey. At Denver Health, purpose isn’t just something we believe in—it’s something we live every day, for life’s journey.

Our Values

Respect | Belonging | Accountability | Transparency

Department

Managed Care Administration

* Must live in Colorado

* This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week.

Job Summary

The Grievance & Appeals Claims Specialist is a key position responsible for handling and resolving client grievances and appeals regarding services and claims. This role ensures that all complaints are addressed promptly and accurately, maintaining compliance with regulatory standards and company policies. The specialist is an advocate for clients, working to resolve issues and improve overall satisfaction while safeguarding the integrity and efficiency of the organization.


Essential Functions:

• Handle and resolve incoming grievances and appeals in a timely and efficient manner (20%)
• Document all complaints, appeals, and resolutions accurately in the system. (20%)
• Conduct thorough investigations to gather necessary information for resolving appeals. (10%)
• Communicate effectively with clients, providers, and internal departments to resolve issues. (10%)
• Ensure compliance with regulatory standards and organizational policies. (10%)
• Collaborate with other departments to address systemic issues and prevent future grievances. (10%)
• Provide regular updates to management on the status of grievances and appeals. (10%)
• Analyze trends in claims grievances and appeals to identify areas for improvement. (10%)

Education:

• High School Diploma or GED required
• Associate's Degree preferred

Work Experience:

• Associates degree and 1 year of claims, customer service, or grievance and appeals experience required

- Or -

• 3 years of experience in the insurance industry required. Claims preferred

- Or -

• 1 year of QNXT experience required

Licenses:
Knowledge, Skills and Abilities:

• Strong knowledge of regulatory requirements and insurance products.
• Excellent communication and interpersonal skills.
• Proven analytical and problem-solving abilities.
• Ability to handle sensitive and confidential information appropriately.
• Proficiency in using relevant software and database systems.
• Strong organizational and time-management skills.
• Understanding of grievance and appeals processes.
• Strong written and verbal communication skills.
• Attention to detail and accuracy.
• Ability to Ability to work independently and as part of a team.
• Ability to manage multiple tasks and meet deadlines.

* Must live in Colorado

* This is a hybrid role located in Denver, Colorado with a requirement of being in the office 2 days per week.

Shift

Days (United States of America)

Work Type

Regular

Salary

$24.10 - $33.74 / hr

Benefits

At Denver Health, we take care of the people who take care of our community. Our benefits are built to support your life, your family, and your future — with generous paid time off, fully paid parental leave, exceptional retirement contributions, comprehensive health coverage, and nationally recognized well-being programs. We invest in your growth through tuition assistance, career advancement pathways, and professional development — while also offering meaningful financial advantages through loan forgiveness eligibility and employer contributions. When you join Denver Health, you’re joining a mission-driven organization that invests in you.

Here is a small list of our benefit programs:

• Paid time off starting at 28 days per year, inclusive of vacation, personal/sick, and 7 Holidays
• 100% paid parental leave up to 6 weeks
• Immediate eligibility for retirement plans with employer contribution up to 9.5%
• Generous medical, dental, vision plans in addition to employer paid disability and life insurance.
• Comprehensive well-being programs including on-site employee fitness center located on Denver Health main campus and nationally recognized RESTORE Center
• Free RTD EcoPass (public transportation)
• Childcare discount programs & exclusive perks on large brands, travel, and more
• Tuition reimbursement & assistance
• Education, coaching, and professional development opportunities through the Workforce Development Center (WFDC) that support internal career growth and advancement pathways
• Professional clinical advancement program & shared governance
• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program
• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

About Denver Health

Denver Health is an integrated, high-quality academic healthcare system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Mountain Poison & Drug Safety, the Public Health Institute at Denver Health, Denver Health Medical Plan and Denver Health Foundation.

As Colorado’s primary, and essential, safety-net healthcare system, Denver Health is a mission-driven organization that has provided millions in uncompensated care for the uninsured each year.

Located near downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas, talents and contributions reflective of the needs of our community. All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made. Applicants will be considered until the position is filled.