Appeals and Grievance Specialist

Job Summary

A company is looking for an Appeals and Grievance Specialist.

Key Responsibilities:

• Manage the resolution process of medical and pharmacy member appeals and complaints/grievances, ensuring compliance with regulatory requirements
• Coordinate management of member complaints and grievances, working with internal departments and external vendors
• Prepare and issue appeal results determination letters and ensure quality and organization of documentation

Qualifications:

• A Bachelor's degree in Health Care Administration or a related field, or equivalent experience
• 2 or more years of experience in a managed care organization
• Experience with Medicare medical and/or pharmacy prior authorization and appeals processes
• Knowledge of CMS, MassHealth, and DHHS contractual provisions and NCQA accreditation requirements
• Experience in conflict resolution is highly preferred