Appeals and Grievances Specialist

Job Summary

A company is looking for a Specialist, Appeals & Grievances (Remote).

Key Responsibilities

• Review and resolve member and provider complaints while ensuring compliance with regulatory timelines
• Research claims appeals and grievances, reviewing medical records and formulating conclusions per protocol
• Prepare appeal summaries and correspondence, ensuring accuracy and compliance with regulatory requirements

Required Qualifications

• High School Diploma or equivalency
• Minimum of 2 years of operational managed care experience
• Health claims processing background, including knowledge of Medicaid and Medicare
• Familiarity with regulatory guidelines for appeals and denials