Appeals and Grievances Specialist

Job Summary

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

Key Responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and complaints from members and providers
• Requests and reviews medical records and formulates conclusions to determine appropriate responses
• Prepares appeal summaries and correspondence, documenting findings in accordance with regulatory requirements

Required Qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment
• Health claims processing experience, including coordination of benefits and eligibility criteria
• Experience with Medicaid and Medicare claims denials and appeals processing
• Customer service experience
• Proficiency in Microsoft Office suite or applicable software programs