Appeals Specialist

Job Summary

A company is looking for an Appeals & Grievances Specialist (Complaints & Grievances).

Key Responsibilities

• Research and resolve appeals, disputes, grievances, and complaints from members and providers while meeting regulatory timelines
• Request and review medical records and claims to determine appropriate outcomes and ensure compliance with guidelines
• 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, 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
• Customer service experience
• Proficiency in Microsoft Office suite or applicable software programs