Grievance & Appeals Specialist

Our Grievance & Appeals Specialist is responsible for reviewing and resolving member and provider grievances, complaints, appeals, and provider claim disputes across the Health Plan division, including Commercial and Medicare product lines. This role ensures all cases are handled accurately, timely, and in full compliance with contractual and regulatory requirements.

This position serves as a key point of coordination between members, providers, and internal partners, working closely with Health Plan Operations, Network Solutions, Pharmacy, Utilization Management, Legal, and other teams to support thorough case review and resolution.

Key responsibilities include reviewing incoming submissions, prioritizing urgent matters, conducting detailed case investigations, maintaining accurate documentation and tracking systems, and composing clear, compliant decision communications. The role also supports compliance audits, reporting on performance metrics, and actively managing case inventory to meet established timelines.

Success in this role requires strong analytical thinking, attention to detail, the ability to manage high-volume workloads, and a commitment to delivering a high-quality, compliant member experience. This Specialist ensures adherence to standards set by Centers for Medicare and Medicaid Services (CMS), Executive Office of the Health and Human Services (EOHHS), Office of the Health Insurance Commissioner (OCI), Utilization Review Accreditation Commission (URAC), and other applicable guidelines.

Hourly Rate of Pay
$25.00 ~ $28.00/hour
The base pay offered for this position may vary within the posted range based on your job-related knowledge, skills, and experience.

We are open to remote work in Wisconsin.
Employees that live within 45 miles of WPS Headquarters (1717 W. Broadway in Madison, WI, 53713) will be expected to be able to be able to work 2 days a week on a regular basis.

How do I know this opportunity is right for me?

• You're skilled at investigating issues, coordinating resolutions, and ensuring timely follow-up with thorough documentation.
• You take pride in compiling detailed case files and supporting materials for review committees.
• You're confident preparing clear, professional written communications that meet regulatory requirements.
• You have experience coordinating external reviews, including preparing submissions, meeting deadlines, and tracking progress.
• You're comfortable interpreting and explaining benefits, policies, and procedures to members, representatives, and providers.
• You communicate effectively to gather information, provide updates, and support decision-making
• You stay organized and can monitor multiple cases at once, ensuring progress and visibility for stakeholders.
• You naturally identify trends and enjoy partnering across teams to improve processes and the member experience.
• You thrive in a role where you support leadership with policies, compliance reporting, and training initiatives.

Minimum Qualifications

• High school diploma or equivalent.
• 3 or more years of experience in healthcare customer service or healthcare grievance and appeals.
• Strong knowledge and understanding of grievance and appeals processes, insurance regulations, and claims adjudication.
• Solid knowledge and understanding of federal and state regulations governing health insurance complaints, grievances, appeals, and member rights.
• Strong written and verbal communication skills with the ability to effectively explain complex information to members, authorized representatives, and providers.
• Strong organizational skills, attention to detail, problem-solving skills and ability to meet strict deadlines.
• Familiarity with health plan operational areas such as customer service, provider service, claims processing, utilization management, pharmacy and dental.

Preferred Qualifications

• Associate's degree or higher in healthcare administration, business, or related field.
• Hands-on experience processing and resolving grievance and appeals in a health plan environment
• Working knowledge of regulatory requirements (e.g., Centers for Medicare and Medicaid Services (CMS), Office of the Health Insurance Commissioner (OCI), and Utilization Review Accreditation Commission (URAC)) and how they apply to day-to-day work.
• Experience using claims or case management systems to track, document, and manage cases.
• Proven ability to manage a high-volume caseload, prioritize urgent items, and consistently meet turnaround time requirements.
• Experience communicating directly with members, providers, or representatives to explain decisions, gather information, and resolve issues.

Remote Work Requirements

• Wired (ethernet cable) internet connection from your router to your computer.
• High speed cable or fiber
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net).
• Please review Remote Worker FAQs for additional information.

Benefits

• Remote and hybrid work options available
• Performance bonus and/or merit increase opportunities
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Professional and Leadership Development Programs
• Review additional benefits: (https://www.wpshealthsolutions.com/careers/)

Who We Are

WPS, a health solutions company, is a leading not-for-profit health insurer and federal government contractor headquartered in Madison, Wisconsin. WPS offers health insurance plans for individuals, families, seniors and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS has been making healthcare easier for the people we serve for nearly 80 years. Proud to be military and veteran ready.

Culture Drives Our Success

WPS' culture is where the great work and innovations of our people are seen, fueled and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce-both current and future-to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.

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