Appeals and Grievances Specialist

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

Key Responsibilities

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

Researches claims appeals and grievances to determine appropriate outcomes and ensures compliance with guidelines

Prepares appeal summaries and correspondence, documenting findings and trends as required

Required Qualifications

At least 2 years of managed care experience in a call center, appeals, 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

Proficiency in Microsoft Office suite or applicable software programs