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 compliance with timelines
• Prepare appeal summaries and correspondence, documenting findings and trends as needed

Required Qualifications

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