Appeals and Grievances Specialist

Job Summary

A company is looking for a Specialist, Appeals & Grievances.

Key Responsibilities

• Research and resolve member and provider complaints, ensuring compliance with regulatory timelines
• Request and review medical records and claims to determine outcomes and prepare appropriate responses
• Prepare appeal summaries and correspondence, documenting findings and trends as necessary

Required Qualifications

• High School Diploma or equivalency
• Minimum of 2 years of operational managed care experience in a call center, appeals, or claims environment
• Experience in health claims processing, including coordination of benefits and eligibility criteria
• Familiarity with Medicaid and Medicare claims denials and appeals processing