Appeals and Grievances Specialist

Job Summary

Providing support for claims activities, the full-time Appeals and Grievances Specialist will manage the resolution of member and provider complaints, ensuring compliance with regulatory standards while working in a dynamic healthcare environment.

Key responsibilities

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

Required qualifications

• At least 2 years of managed care experience in a call center, appeals, and/or claims environment
• Experience with Medicaid and Medicare claims denials and appeals processing
• Health claims processing experience, including coordination of benefits and eligibility criteria
• Strong organizational and time management skills
• Proficiency in Microsoft Office suite or applicable software programs