Appeals and Grievances Specialist

Job Summary

Providing essential support for claims activities, the full-time Appeals and Grievances Specialist will manage the resolution of member and provider complaints, ensuring compliance with CMS standards while working remotely.

Key responsibilities

• Facilitates research and resolution of appeals, grievances, and complaints from members and providers, meeting regulatory timelines
• Requests and reviews medical records and claims to determine appropriate outcomes and prepares documentation accordingly
• Communicates with members and providers through written and verbal correspondence, ensuring clarity and compliance with regulatory requirements

Required qualifications

• At least 2 years of managed care experience in a call center, appeals, or claims environment
• Experience with Medicaid and Medicare claims, including knowledge of regulatory guidelines for appeals and denials
• Health claims processing experience, including coordination of benefits and eligibility criteria
• Strong organizational and time management skills to manage multiple projects effectively
• Proficiency in Microsoft Office suite and applicable software programs