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Appeals and Grievance Specialist

7/11/2025

No location specified

Job Summary

A company is looking for an Appeals and Grievance Specialist responsible for managing the resolution process of medical and pharmacy member appeals and complaints.

Key Responsibilities:
  • Manage member appeals and grievances, ensuring compliance with regulatory requirements and accreditation standards
  • Coordinate with internal departments and external vendors to resolve member complaints and grievances
  • Prepare and issue appeal determination letters and maintain organized documentation of appeals and grievances


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 prior authorization processes
  • Comprehensive knowledge of CMS, MassHealth, and DHHS contractual provisions
  • Knowledge of NCQA accreditation requirements is highly desirable

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