Appeals and Grievances Specialist

Job Summary

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

Key responsibilities

• Facilitates comprehensive research and resolution of appeals, grievances, and complaints from members and providers
• Requests and reviews medical records and claims documentation to determine appropriate outcomes
• Prepares appeal summaries and correspondence, documenting findings in accordance with regulatory requirements

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 meet deadlines
• Effective verbal and written communication skills
• Proficiency in Microsoft Office suite and applicable software programs