Appeals and Grievances Specialist

Job Summary

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

Key Responsibilities

• Research and resolve appeals, disputes, grievances, and complaints from members and providers, ensuring compliance with timelines
• Review medical records and claims to determine appropriate outcomes and prepare documentation accordingly
• Communicate with members and providers, and prepare appeal summaries and correspondence in line with regulatory requirements

Required Qualifications

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