Grievance & Appeals Specialist - Remote

Overview

This role combines the responsibilities of utilization review with grievance and appeals management to ensure compliance with healthcare regulations and promote quality patient care.

In Short

• Review medical records and claims to assess the appropriateness and necessity of healthcare services.
• Ensure adherence to clinical guidelines, payer policies, and regulatory requirements.
• Collaborate with healthcare providers to facilitate prior authorizations and medical necessity reviews.
• Monitor patient care to optimize resource utilization.
• Document and report findings for compliance with healthcare standards.
• Investigate and resolve member and provider appeals and grievances.
• Communicate appeal determinations clearly to stakeholders.
• Ensure compliance with state and federal regulations.
• Maintain thorough documentation for reporting and audit purposes.
• Identify trends and recommend process improvements.

Requirements

• Higher education in Healthcare Administration or related field preferred.
• 2+ years of experience in utilization review or appeals processing.
• Strong knowledge of medical necessity criteria.
• Familiarity with Medicare, Medicaid, and commercial insurance policies.
• Excellent analytical and problem-solving abilities.
• Strong written and verbal communication skills.
• Proficiency in medical terminology, coding, and claims processing.
• Ability to work independently and meet deadlines.

Benefits

• Dental and Vision coverage.
• Short-term and Long-term Disability Insurance.
• Voluntary Life & AD&D Insurance.
• Accident and Critical Illness Insurance.
• Health Advocate EAP.
• Health Equity Commuter Benefits.
• ZayZoon.
• 401k plan.