Lead Appeals and Grievances Specialist

Job Summary

Serving as a team lead, the full-time Lead Appeals and Grievances Specialist will manage the submission, intervention, and resolution of appeals and grievances from members and providers, while training new employees and resolving escalated issues in compliance with CMS standards.

Key responsibilities

• Oversee the resolution of complex appeals and grievances, ensuring compliance with regulatory guidelines
• Train and guide team members on handling appeals and grievances effectively
• Research and resolve escalated issues, preparing documentation and summaries for tracking and audits

Required qualifications

• At least 3 years of managed care experience in a call center, appeals, and/or claims environment
• Experience with Medicaid and Medicare claims denials and appeals processing
• Strong customer service experience and proficiency in Microsoft Office suite
• Ability to manage multiple projects and tasks to meet deadlines
• Knowledge of health claims processing, including coordination of benefits and eligibility criteria