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 in a remote environment.

Key responsibilities

• Facilitates comprehensive research and resolution of appeals, grievances, and complaints from members and providers
• Requests and reviews medical records and documentation to determine appropriate outcomes for claims appeals
• Prepares appeal summaries and correspondence, ensuring compliance with regulatory requirements and internal standards

Required qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment
• Health claims processing experience, including knowledge of Medicaid and Medicare claims denials and appeals
• Strong organizational and time management skills to manage multiple projects and deadlines
• Effective verbal and written communication skills
• Proficiency in Microsoft Office suite and applicable software programs