Massachusetts Licensed Appeals Specialist

Job Summary

A company is looking for a Member Appeals Specialist to support a high-volume appeals and grievances function within a regulated healthcare environment.

Key Responsibilities

• Manage the full lifecycle of member appeals, ensuring adherence to regulatory timelines and internal standards
• Triage incoming appeals and grievances, accurately categorize cases, and assign or route work as appropriate
• Review appeal requests for eligibility and completeness, and draft acknowledgment and determination letters

Required Qualifications

• 2+ years of experience handling member appeals within a healthcare or health plan environment
• Experience managing appeals cases end-to-end within a case management or appeals system
• Strong understanding of regulatory timelines and compliance requirements related to appeals and grievances
• Ability to manage a high-volume caseload while maintaining accuracy and organization
• Comfortable navigating multiple systems and tools in a remote work environment