Lead Appeals and Grievances Specialist

Job Summary

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

Key Responsibilities

• Lead a team in the submission, intervention, and resolution of appeals and grievances
• Research and resolve escalated issues, preparing summaries and documentation for tracking
• Ensure compliance with regulatory standards in handling member and provider complaints

Required Qualifications

• High School Diploma or equivalency
• Minimum of 3 years of operational managed care experience
• Experience in health claims processing, including knowledge of Medicaid and Medicare
• Familiarity with regulatory guidelines for appeals and denials