Appeals and Grievances Specialist

Job Summary

A company is looking for a Specialist, Appeals & Grievances.

Key Responsibilities

• Review and resolve member and provider complaints in accordance with regulatory standards
• Research claims appeals and grievances to determine outcomes and ensure timely responses
• Prepare appeal summaries and correspondence, ensuring compliance with regulatory requirements

Required Qualifications

• High School Diploma or equivalency
• Minimum 2 years of operational managed care experience
• Health claims processing background, including knowledge of Medicaid and Medicare
• Familiarity with regulatory guidelines for appeals and denials