Appeals and Grievance Specialist

Job Summary

A company is looking for an Appeals and Grievance Specialist responsible for managing member appeals and grievances while ensuring compliance with regulations and standards.

Key Responsibilities:

• Manage member appeals and grievances, ensuring compliance with relevant regulations and standards
• Coordinate with internal departments and external vendors to facilitate the resolution of complaints and grievances
• Prepare and issue determination letters and reports related to appeals and grievances

Required Qualifications:

• Bachelor's degree in Health Care Administration or related field, or equivalent experience
• Minimum of 2 years' experience in a managed care organization
• Experience with Medicare medical and/or pharmacy prior authorization and appeals processes
• Comprehensive knowledge of CMS, MassHealth, and DHHS regulations
• Knowledge of NCQA accreditation requirements is highly desirable