Appeals and Grievances Specialist

Summary

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Make An Impact

In Medicare Advantage Member Experience

Primary Responsibilities

• Investigate and resolve member and provider appeals and grievances, ensuring timely, accurate, and compliant case resolution while helping deliver an exceptional member experience.
• Play a critical role in supporting regulatory compliance, operational excellence, and quality improvement initiatives across the organization.

Essential Duties & Responsibilities

• Investigate and resolve member and provider appeals and grievances in a professional, accurate, and timely manner while meeting all contractual and regulatory timeframes.
• Maintain a clear understanding of the differences between medical necessity appeals and claim appeals and apply appropriate processes accordingly.
• Manage appeals and grievance cases from intake through final resolution, including receiving, logging, tracking, monitoring, documenting, requesting supporting documentation, investigating, auditing, resolving, and reporting on cases.
• Respond to member and provider appeals and grievances independently and with minimal supervision.
• Interface with members and providers regarding the status, process, and outcomes of complaints, appeals, and grievances.
• Prepare all appeal and grievance-related correspondence, including acknowledgment letters, determination letters, outcome notifications, and correspondence for escalated levels of review.
• Prepare, attend, and present appeals and grievances documentation for plan hearings, regulatory reviews, audits, and other compliance-related activities as needed.
• Accurately document all appeal and grievance activities, follow-up actions, and final outcomes in designated systems while maintaining comprehensive and secure case files.
• Generate reports, identify trends, and provide recommendations for quality improvement initiatives and operational enhancements.
• Communicate detailed risk management concerns and compliance-related issues to leadership within established timeframes.
• Review appeal and grievance correspondence and proactively obtain additional information from appellants, providers, or other stakeholders as necessary.
• Partner closely with member advocates and internal stakeholders to facilitate effective grievance resolution and an exceptional member experience.
• Assist in coordinating peer review activities involving internal Physician Advisors and external review vendors.
• Collaborate with Utilization Management, Claims, Provider Network, Legal, Compliance, and other business partners to ensure appeal and grievance decisions align with all regulatory, contractual, and organizational requirements.
• Work with leadership and external vendors to resolve complex, high-profile, and escalated appeals and grievance cases.

Qualifications

• High school diploma or GED required.
• Minimum of three (3) years of experience managing Medicare Advantage appeals and grievances.
• Experience working for a Medicare Advantage health plan.
• Experience within Medicare Advantage health insurance, including appeals, grievances, customer service, and complaint resolution.
• Working knowledge of Medicare Advantage regulations, appeals processes, grievance procedures, and complaint resolution requirements.
• Experience investigating and resolving complex member and provider issues in a highly regulated healthcare environment.
• Strong written and verbal communication skills, including the ability to prepare professional correspondence, determination letters, and case documentation.
• Proficiency with Microsoft Office applications, including Word and Excel.
• Strong analytical, organizational, problem-solving, and critical-thinking skills.
• Ability to effectively manage multiple priorities, meet strict deadlines, and maintain a high degree of accuracy and attention to detail.
• Ability to interpret, apply, and adhere to regulatory requirements, policies, and procedures.

Preferred Qualifications

• Experience utilizing appeals and grievances platforms such as QNXT.
• Experience supporting audits, regulatory reviews, compliance activities, or accreditation requirements.