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 CMS standards while working in a remote environment.

Key responsibilities

• Conduct comprehensive research and resolution of appeals, grievances, and complaints from members and providers
• Request and review medical records and claims to determine appropriate outcomes and ensure timely responses
• 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, or claims environment
• Health claims processing experience, including knowledge of Medicaid and Medicare claims denials and appeals
• Strong organizational and time management skills to handle multiple projects and meet deadlines
• Effective verbal and written communication skills
• Proficiency in Microsoft Office suite and applicable software programs