Appeals and Grievances Specialist

Job Summary

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

Key Responsibilities

• Review and resolve member and provider complaints while ensuring compliance with regulatory timelines
• Research claims appeals and grievances, including the review of medical records and claims processing guidelines
• Prepare appeal summaries and correspondence, ensuring accuracy and adherence to regulatory requirements

Required Qualifications

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