Appeals And Grievance Specialist

Appeals and Grievance Specialist Overview

• The Appeals and Grievance Specialist role involves handling complaints, appeals, and disputes from members and providers.
• This position requires meticulous attention to detail and the ability to work independently.
• The role supports compliance with NCQA, CMS, and state regulations.
• Candidates will process appeals and grievances, ensuring accurate administration of benefits and clinical policy.
• The position requires proficiency in technology and data entry tasks.
• This is a contract role with a focus on clearing departmental backlog by year-end.
• Candidates should possess excellent communication and problem-solving skills.
• The role offers the opportunity to contribute to quality improvement and operational efficiency.

Appeals and Grievance Specialist Key Responsibilities & Duties

• Review and evaluate appeal and grievance requests to classify member and provider appeals.
• Determine eligibility, benefits, and prior activity related to claims or services.
• Conduct thorough investigations and obtain information from internal and external entities.
• Prepare cases for medical and administrative review, detailing findings and resolutions.
• Monitor pending reports and worklists to ensure regulatory timeframes are met.
• Provide written responses to member and provider correspondence, addressing issues accurately.
• Collaborate with departments and entities to ensure timely resolution of cases.
• Identify areas for improvement and recommend solutions to management.
• Perform administrative tasks such as data entry and duplicate review.

Appeals and Grievance Specialist Job Requirements

• Associate Degree in a related field required; Bachelor’s degree preferred.
• Minimum of 3 years of professional experience, preferably in health industry or compliance.
• Proficiency in MS Office applications, especially word processing and spreadsheets.
• Exceptional verbal and written communication skills with error-free correspondence ability.
• Strong problem-solving, analytical, and organizational skills.
• Ability to work under pressure and deliver accurate, timely results.
• Customer service experience and knowledge of managed care/compliance environments.
• Attention to detail and the ability to work independently.
• Technology-savvy with experience in data entry and administrative tasks.