Lead Appeals and Grievances Specialist

Job Summary

A company is looking for a Lead Specialist, Appeals & Grievances.

Key Responsibilities

• Lead and organize the Grievance and Appeals Unit's activities, ensuring compliance with regulatory standards
• Review and evaluate member grievances and appeals, coordinating with appropriate departments for resolution
• Conduct investigations into escalated issues and provide written responses to member correspondence

Required Qualifications

• High School Diploma or equivalent
• 3 years of experience in appeals and grievances
• Minimum of 3 years in an operational managed care environment
• Health claims processing experience, including knowledge of Medicaid and Medicare guidelines
• Familiarity with regulatory requirements for appeals and denials