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 compliance with regulatory standards
• Research claims appeals and grievances, ensuring timely and appropriate responses
• Prepare appeal summaries and correspondence, documenting findings and trends as necessary

Required Qualifications

• High School Diploma or equivalency
• Minimum 2 years of operational managed care experience
• Experience in health claims processing, including coordination of benefits and eligibility criteria
• Familiarity with Medicaid and Medicare claims denials and appeals processing