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 regulatory standards.

Key Responsibilities:

• Manage and execute member appeals across departments and with external vendors
• Coordinate and resolve member complaints and grievances, ensuring compliance with regulations
• Prepare and issue appeal determination letters and maintain organized documentation

Required Qualifications:

• Bachelor's degree in Health Care Administration or related field, or equivalent experience
• 2+ years of experience in a managed care organization
• Experience with Medicare medical and pharmacy appeals processes
• Knowledge of CMS, MassHealth, and DHHS regulations is highly desirable
• Experience in conflict resolution is preferred