Appeals and Grievance Specialist

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