Quality Assurance Specialist – Appeal & Grievance

Alignment Health

Quality Assurance Specialist responsible for Appeals and Grievances data oversight. Ensuring regulatory compliance and supporting quality improvement initiatives in a remote environment.

Posted 4/30/2026full-timeRemote • California • 🇺🇸 United StatesJuniorMid-Level💰 $48,373 - $72,559 per yearWebsite

About the role

Key responsibilities & impact

Monitors timeliness with Appeals and Grievances data
Reviews case work end-to-end, ensuring workflow procedures are met to achieve Star Measure goals
Analyzes and validates accuracy of Appeals and Grievance data according to plan business and CMS regulatory technical reporting requirements
Validates and assists with enforcing that all complaint types are processed according to plan procedure and in compliance with the CMS guidelines
Produces departmental quality performance reports for management review
Manipulates and analyzes data from multiple report sources for quality review
Assists with the preparation of audit universes and case samples
Identifies training opportunities and potential system and process improvements relating to appeals and grievance data
Assists with training and systems applications User Agreement Testing (UAT)
Participates in departmental and regulatory compliance audits
Maintains confidentiality and Health Insurance Portability and Accountability Act (HIPAA) compliance to ensure Protection of Health Information (PHI)

Requirements

What you’ll need

2+ years of healthcare appeals & grievances experience, related QA experience, or training/supervisory role
2+ years of managed healthcare experience
High School Diploma or GED with relevant work experience
Bachelor’s degree in Healthcare, Business, or related field with relevant work experience preferred
Possess the knowledge of Appeals and Grievance procedures and the Centers for Medicare (CMS) regulatory compliance guidelines
Strong attention-to-detail, analytical, problem solving and critical thinking
Knowledge of Medicare Managed Care Plans required
Demonstrated knowledge of CMS Reporting (ODAG, Stars Measures, etc.)

Benefits

Comp & perks

Health insurance
Retirement plans
Paid time off
Flexible work arrangements
Professional development opportunities

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

data analysisquality assuranceregulatory complianceaudit preparationuser agreement testingreport generationdata manipulationcase reviewworkflow proceduresCMS reporting

Soft Skills

attention to detailanalytical skillsproblem solvingcritical thinkingtraining identificationcommunicationorganizational skillsconfidentiality maintenanceprocess improvementteam collaboration