Appeals and Grievances Specialist

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

Key Responsibilities

Review and resolve member and provider complaints in accordance with regulatory standards

Conduct comprehensive research on appeals, grievances, and claims to determine outcomes

Prepare documentation and correspondence related to appeals and grievances, ensuring compliance with regulations

Required Qualifications

High School Diploma or equivalency

Minimum of 2 years of operational managed care experience

Experience in health claims processing, including coordination of benefits and eligibility criteria

Familiarity with Medicaid and Medicare claims denials and appeals processing