Appeals and Grievance Specialist

Job Summary

Managing the resolution process for medical and pharmacy member appeals and grievances, the full-time remote Appeals and Grievance Specialist will ensure compliance with regulatory requirements and accreditation standards while coordinating with internal departments and external vendors.

Key responsibilities:

• Execute member appeals across multiple departments and ensure compliance with CMS, MassHealth, and DHHS directives
• Coordinate management of member complaints and grievances, collaborating with clinical staff to investigate and implement corrective actions
• Prepare and issue appeal results determination letters and ensure quality documentation for appeals and grievances

Required qualifications:

• Bachelor's degree in Health Care Administration or a related field, or equivalent combination of education and experience
• Minimum of 2 years' experience in a managed care organization, specifically with Medicare appeals and grievances processes
• Comprehensive knowledge of CMS, MassHealth, and DHHS contractual provisions
• Experience with conflict resolution preferred
• Strong working knowledge of Microsoft Office products