Grievances & Appeals Representative

Location: Remote, Puerto Rico; candidates must reside in Puerto Rico. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m., with flexibility for schedule changes and overtime. Remote training begins September 21 and lasts approximately 8–10 weeks; attendance is mandatory throughout training. Occasional travel to hirify.global offices for training or meetings may be required.

Salary: $34,400–$45,000 per year.

Company

hirify.global is a U.S. healthcare and health insurance company serving Medicare, Medicaid, military, individual, and family healthcare members.

What you will do

• Review clinical documentation and analyze member denials, grievances, appeals, and further requests.
• Issue final determinations using established procedures and collaboration with clinical and operational partners.
• Investigate and resolve member and practitioner issues by phone and through administrative review.
• Maintain accurate records and process data while meeting productivity and quality objectives.
• Prioritize requests independently and adapt administrative processes using professional judgment.

Requirements

• Must reside in Puerto Rico.
• Bilingual English and Spanish proficiency is required, with the ability to read, write, and speak both languages without limitations or assistance.
• At least two years of customer service experience.
• Experience in healthcare or a medical field and in a production-driven environment.
• Proficiency in data entry and record management with high accuracy.
• Intermediate Microsoft Word and Excel skills.

Nice to have

• Associate or bachelor’s degree.
• Grievance and appeals, medical claims, Medicare, or inbound call center experience.
• Experience with the Claims Administration System (CAS) and knowledge of medical terminology.
• Ability to manage high volumes of documents, including tracking, copying, faxing, and scanning.
• Strong interpersonal skills for compassionate interaction with geriatric members.

Culture & Benefits

• Fully remote work with a dedicated workspace required to protect member PHI and HIPAA information.
• Home internet must provide at least 25 Mbps download and 10 Mbps upload speeds.
• Full-time schedule of 40 hours per week with paid time off, holidays, and parental and caregiver leave.
• Medical, dental, vision, life insurance, short- and long-term disability, and 401(k) benefits.
• Training and meetings may occasionally take place at hirify.global offices.