Senior Policy and Appeals Specialist

A Little More about the Role:

The Senior Policy and Appeals Specialist provides advanced-level expertise in appeals processing, responsible for the comprehensive review, investigation, and resolution of Member appeals and provider disputes for Gravie. This role ensures compliance with self-funded plan documents, employer group requirements, and applicable federal and state regulations.

You Will:

• Review, investigate, and adjudicate complex post-service, urgent, ERISA, and non-ERISA member appeals and provider disputes across multiple product lines.

• Interpret plan documents (SPDs, SBCs), employer exceptions, stop-loss provisions, and apply plan policy accurately to benefit determinations.

• Analyze claims, medical records, coding, and supporting documentation to ensure fair, accurate, and compliant decisions.

• Ensure appeals and disputes are resolved within regulatory requirements (ERISA, ACA, state mandates) and internal SLAs.

• Draft clear, compliant determination letters outlining decisions and rationale.

• Collaborate with department directors, clinical, compliance, legal, network, claims operations, customer service, and account management to resolve escalations and complex cases.

• Escalate high-risk, litigation-sensitive, or regulatory matters to leadership as appropriate.

• Participate in audits, DOI complaint investigations, and regulatory reviews.

• Identify trends, root causes, and systemic issues; provide reporting and monthly results to senior leadership.

• Assist in developing and updating policies, procedures, workflows, and best practices.

• Serve as subject matter expert on appeals, plan interpretation, and network pricing disputes.

• Mentor and provide technical guidance to appeals staff while balancing quality and productivity standards.

• Maintain effective communication with members, providers, attorneys, and internal stakeholders, managing conflict professionally.

• Present appeal cases to the Appeal and Exception committees, providing detailed description, to ensure committees can make determination.

You Bring:

• High School Diploma

• 6 + years of experience processing/adjusting and/or analyzing medical claims preferably in a TPA environment

• 3 + years of experience with medical appeals and provider disputes

• Ability to set priorities, manage time and work independently

• Basic proficiency using Windows based other computer applications

• Functional comfort with Zoom, Microsoft Teams, or Google Meets

• General knowledge of CMS claims submission regulations

• Demonstrated success getting results through collaboration

• Excellent facilitation and transferable knowledge skills communicating effectively on complex concepts

• Proven ability to develop and implement appeals and disputes processes

• Experience in managing and assigning claims inventory

• Medical Coding experience/ Certification

• Medical Billing experience

• Understanding of provider data

• Previous start-up company experience

• Degree in Healthcare Administration or similar field

Gravie:

In order to create a more equitable and sustainable future for employer-sponsored health insurance, we need talented people doing amazing work. In exchange, we offer a great overall employee experience with opportunities for career growth, meaningful mission-driven work, and an above average total rewards package.

The salary range for this position is $50,400 - $84,000 annually. Numerous factors including, but not limited to, education, skills, work experience, certifications, etc. will be considered when determining compensation.

Our unique benefits program is the gravy, i.e., the special sauce that sets our compensation package apart. In addition to standard health and wellness benefits, Gravie’s package includes alternative medicine coverage, generous PTO, up to 16 weeks paid parental leave, paid holidays, a 401k program, transportation perks, education reimbursement, and paid paw-ternity leave.