Appeals and Grievances Specialist

Job Summary

Facilitating the resolution of member and provider complaints, the full-time Appeals and Grievances Specialist will manage claims activities, ensuring compliance with regulatory standards while working remotely.

Key responsibilities

• Research and resolve appeals, disputes, grievances, and complaints from members and providers, adhering to internal and regulatory timelines
• Request and review medical records and bills to formulate conclusions and ensure timely responses according to guidelines
• Prepare appeal summaries and correspondence, documenting findings and trends as required

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
• Strong organizational and time management skills
• Proficiency in Microsoft Office suite or applicable software programs