Appeals and Grievances Specialist

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

Key Responsibilities

Review and resolve member and provider complaints, ensuring compliance with regulatory timelines

Research claims appeals and grievances, including reviewing medical records and formulating conclusions

Prepare appeal summaries and correspondence, documenting findings and trends as needed

Required Qualifications

High School Diploma or equivalency

Minimum of 2 years operational managed care experience

Health claims processing experience, including knowledge of Medicaid and Medicare guidelines

Familiarity with appeals processing and regulatory requirements