Appeals Specialist

Job Summary

A company is looking for a Specialist in Appeals & Grievances with Member/Provider Experience.

Key Responsibilities:

• Review and resolve member and provider complaints/disputes in accordance with established standards
• Research and determine appeal and grievance outcomes using support systems
• Contact members/providers through written and verbal communication and prepare appeal summaries

Required Qualifications:

• High School Diploma or equivalency
• Minimum 2 years operational managed care experience (appeals or claims processing)
• Health claims processing background, including Medicaid and Medicare knowledge
• Familiarity with regulatory guidelines for appeals and denials
• Experience in researching claims processing guidelines and provider contracts