Appeals & Grievance Specialist I

Appeals & Grievance Specialist I

Samaritan Health Plans (SHP) provides health insurance options to Samaritan employees, community employers, and Medicare and Medicaid members. SHP operates a portfolio of health plan products under several different legal structures : InterCommunityHealth Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan.

As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together.

Candidates residing out of state will need to be able to work Pacific Time Zone hours.

This is a remote position in which we are able to employ in the following states : Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin

JOB SUMMARY / PURPOSE

Plays a vital role in managing and resolving member and provider appeals and grievances. This position requires exceptional communication skills, keen attention to detail, and a commitment to compliance with regulatory standards. Responsible for investigating, documenting, and facilitating resolutions; and ensuring member and provider satisfaction throughout the process.

DEPARTMENT DESCRIPTION

Samaritan Health Plans (SHP) operates a portfolio of health plan products under several different legal structures : InterCommunity Health Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together.

EXPERIENCE / EDUCATION / QUALIFICATIONS

Bachelor’s degree in healthcare, business, or a related field; or equivalent relevant experience required.

Experience in computer applications, including Microsoft Office Suite, required.

Experience in appeals and grievances strongly preferred.

KNOWLEDGE / SKILLS / ABILITIES

Familiarity with healthcare laws, regulations, and best practices related to appeals and grievances.

Strong problem-solving, organizational, and time-management skills. Attention to detail and commitment to accuracy in documentation and reporting.

Excellent verbal and written communication abilities to clearly convey complex information.

Ability to manage multiple cases simultaneously and meet deadlines in a fast-paced environment. Ability to manage deadlines while adhering to quality and compliance standards.

Commitment to exceptional customer service and stakeholder engagement.

Proficiency in case management software and ability to adapt to new technology.

PHYSICAL DEMANDS

Rarely

(1 - 10% of the time)

Occasionally

(11 - 33% of the time)

Frequently

(34 - 66% of the time)

Continually

(67 – 100% of the time)

CLIMB - STAIRS

LIFT (Floor to Waist : 0"-36") 0 - 20 Lbs

LIFT (Knee to chest : 24"-54") 0 – 20 Lbs

LIFT (Waist to Eye : up to 54") 0 - 20 Lbs

CARRY 1-handed, 0 - 20 pounds

BEND FORWARD at waist

KNEEL (on knees)

STAND

WALK – LEVEL SURFACE

ROTATE TRUNK Standing

REACH - Upward

PUSH (0 - 20 pounds force)

PULL (0 - 20 pounds force)

SIT

CARRY 2-handed, 0 - 20 pounds

ROTATE TRUNK Sitting

REACH - Forward

MANUAL DEXTERITY Hands / wrists

FINGER DEXTERITY

PINCH Fingers

GRASP Hand / Fist

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