Appeals and Grievance Specialist

Job Summary

Managing the full life cycle of member and provider appeals and grievance cases, the full-time Appeals and Grievance Specialist will conduct case intake, investigation, and documentation to ensure timely resolution while working remotely.

Key responsibilities

• Research and analyze case documentation to clarify appeal intent and gather necessary information
• Collaborate with internal departments to resolve cases and identify compliance issues requiring escalation
• Ensure case handling meets federal and state regulatory requirements while maintaining confidentiality and documentation standards

Required qualifications

• Associate's Degree in Health Administration, Business, or a related field preferred
• High School Diploma or GED required
• 2 to 3 years of experience in healthcare operations, managed care, or grievance/appeals coordination
• Knowledge of medical terminology, benefit interpretation, and regulatory processes preferred
• Proficiency in Microsoft Office Suite (Word, Excel, Outlook, etc.)