Specialist, Admin Complaints, Grievances & Appeals

Oscar Health is a health insurance company that focuses on serving its members through a technology-driven platform. The Specialist, Admin Complaints, Grievances & Appeals will manage and resolve complex administrative grievances and appeals, ensuring compliance with regulatory standards and championing member satisfaction. Responsibilities Follow established workflows to acknowledge, log, and perform initial triage on complex or escalated administrative grievances from members and/or providers Conduct thorough, multi-faceted investigations by gathering and analyzing internal data, call logs, correspondence, etc Use workflows to reconstruct complex event timelines involving prior authorizations, claims processing, and system-based adjudication edits to accurately determine the root cause of member and/or provider issues Liaise with internal departments, such as Member Services, Eligibility & Benefits, and Claims, to obtain necessary information for complete case resolution Based on investigative findings, determine a resolution strategy that is both fair and compliant with company and regulatory guidelines, utilizing established workflows Escalate the issue to leadership for further guidance on resolution strategy, as needed Draft clear, accurate, complete resolution letters, ensuring all required regulatory elements are included Maintain meticulous and comprehensive case files in the case management system to ensure a clear and complete audit trail for each case Monitor and manage case timelines to ensure strict adherence to all federal and state mandated deadlines Compliance with all applicable laws and regulations Other duties as assigned Skills 1+ years of professional experience in a regulated industry, such as healthcare, insurance 1+ years of experience independently managing a demanding caseload with multi-step workflows, from initial intake through investigation, resolution, and final documentation, while meeting competing priorities 1+ years of experience with directly managing escalated customer, member or provider cases 1+ years of experience with drafting and issuing formal written communication to member or providers 1+ years of experience working in a highly structured, workflow driven, environment Bilingual in Spanish (reading and writing) Bachelor's degree Experience in health care administration Involvement in departmental or cross-functional process improvement or quality initiatives Benefits Medical, dental, and vision benefits 11 paid holidays Paid sick time Paid parental leave 401(k) plan participation Life and disability insurance Paid wellness time and reimbursements Company Overview Oscar is a health insurance company that offers individual and family plans, medicare advantages, and small group products. It was founded in 2012, and is headquartered in New York, New York, USA, with a workforce of 1001-5000 employees. Its website is Company H1B Sponsorship Oscar Health has a track record of offering H1B sponsorships, with 16 in 2025, 24 in 2024, 22 in 2023, 36 in 2022, 13 in 2021. Please note that this does not guarantee sponsorship for this specific role.