A company is looking for an Appeals and Grievances Specialist to ensure timely resolutions to member complaints and appeals in compliance with regulatory requirements.
Key ResponsibilitiesReview and process member appeals related to healthcare services and claimsConduct investigations of member appeals and grievances, collaborating with internal departmentsMaintain detailed case documentation and prepare reports on appeals and grievances activityRequired Qualifications and EducationBachelor's degree in healthcare administration, business, public health, or a related field preferred2+ years of experience in healthcare appeals and grievances, claims, or related member services rolesFamiliarity with health plan operations and regulatory compliance for Medicare, Medicaid, and commercial insuranceStrong knowledge of healthcare regulations and managed care policiesProficiency in Microsoft Office and healthcare management systems
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