Specialist, Appeals & Grievances - Remote

Overview

The Specialist for Appeals & Grievances is responsible for reviewing and resolving member and provider complaints, ensuring compliance with standards set by the Centers for Medicare and Medicaid.

In Short

• Review and resolve member and provider complaints.
• Conduct comprehensive research on appeals and grievances.
• Request and review medical records and detailed bills.
• Meet production standards set by the department.
• Communicate resolutions to members and providers.
• Prepare appeal summaries and correspondence.
• Research claims processing guidelines and contracts.
• Resolve provider reconsideration requests related to claims.
• Ensure compliance with regulatory requirements.
• Utilize strong verbal and written communication skills.

Requirements

• High School Diploma or equivalent.
• Minimum 2 years operational managed care experience.
• Health claims processing background.
• Familiarity with Medicaid and Medicare claims.
• Strong verbal and written communication skills.

Benefits

• Competitive benefits and compensation package.
• Equal Opportunity Employer (EOE) M/F/D/V.