Manager of Appeals and Grievances

Job Summary

Leading a team remotely, the full-time Manager of Appeals and Grievances will manage claims activities, resolve member and provider complaints, and ensure compliance with CMS standards.

Key responsibilities

• Manage the submission and resolution of member and provider appeals and grievances, ensuring compliance with applicable standards
• Assess and audit business processes for effective resolution of grievances while maintaining production standards
• Serve as the primary interface with stakeholders, overseeing preparation of reports and correspondence as per regulatory requirements

Required qualifications

• At least 7 years of managed care experience in a call center, appeals, and/or claims environment
• A minimum of 1 year of management or leadership experience
• Experience with Medicaid and Medicare claims denials and appeals processing
• Proficiency in reviewing various types of medical claims
• Previous project leadership experience