Appeals and Grievance Specialist

Job Summary

A company is looking for a Member Appeals & Grievances Specialist - Remote EST.

Key Responsibilities

• Review and resolve member disputes, complaints, and grievances in accordance with regulatory standards
• Research claims appeals and grievances, including medical records and billing, to determine outcomes
• Prepare appeal summaries and correspondence while ensuring compliance with regulatory requirements

Required Qualifications

• High School Diploma or equivalent
• Minimum of 2 years of operational managed care experience
• Health claims processing background, including knowledge of Medicaid and Medicare
• Familiarity with regulatory guidelines for appeals and denials