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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