Appeals and Grievances Specialist

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

Key Responsibilities

Facilitates research and resolution of appeals, disputes, grievances, and complaints from members and providers

Researches claims appeals and grievances to determine appropriate outcomes and prepares documentation accordingly

Contacts members and providers as needed, ensuring compliance with regulatory guidelines and internal standards

Required Qualifications

At least 2 years of managed care experience in a call center, appeals, and / or claims environment

Health claims processing experience, including coordination of benefits and eligibility criteria

Experience with Medicaid and Medicare claims denials and appeals processing

Customer service experience

Strong organizational and time management skills