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 and external stakeholders.

Key responsibilities:

• Executes member appeals and coordinates management of complaints and grievances across departments
• Ensures compliance with CMS, MassHealth, and DHHS directives while preparing and issuing appeal determination letters
• Investigates grievances related to quality of care and implements corrective action plans as needed

Required qualifications:

• Bachelor's degree in Health Care Administration or a related field, or equivalent combination of education and experience
• Two or more years of experience in a managed care organization
• Experience with Medicare medical and/or pharmacy prior authorization processes
• Comprehensive knowledge of CMS, MassHealth, and DHHS contractual provisions
• Knowledge and experience in conflict resolution highly preferred