Appeals and Grievances Specialist

Job Summary

To support claims activities, the full-time Appeals and Grievances Specialist will manage the resolution of member and provider complaints, ensuring compliance with CMS standards while conducting thorough research and documentation of appeals and grievances.

Key responsibilities

• Facilitates research and resolution of appeals, disputes, grievances, and complaints from members and providers
• Requests and reviews medical records and claims information to determine appropriate outcomes and responses
• Prepares appeal summaries, correspondence, and documents 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 coordination of benefits and eligibility criteria
• Experience with Medicaid and Medicare claims denials and appeals processing
• Strong organizational and time management skills to handle multiple projects
• Proficiency in Microsoft Office suite or applicable software programs