Appeals & Grievance Case Resolution Specialist

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 50 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

About the Role

AmeriHealth Caritas is seeking talented, passionate individuals to join our team as an Appeals & Grievance Case Resolution Specialist. This role is responsible for the full life cycle of assigned member and/or provider appeals and grievance cases, ensuring accurate and timely resolution consistent with federal, state, and accreditation standards. The Specialist serves as a key liaison between members, providers, and internal departments to resolve issues effectively while maintaining compliance with CMS, NCQA, URAC, and state regulatory requirements.

Responsibilities

• Case Management
  • Research and analyze case documentation, including benefit coverage, prior authorizations, claims, and regulatory guidance.
  • Communicate with members, providers, or representatives to clarify appeal intent and gather missing documentation, including handling incoming calls, outgoing calls, and phone queue work as assigned.
  • Prepare complete and compliant case files, ensuring all required documentation is included.
  • Track case progress and maintain compliance with turnaround times and documentation standards.
  • Generate accurate and timely determination and acknowledgement letters.
• Investigation and Resolution
  • Collaborate with internal departments such as Claims, Medical Management, Legal, and Compliance to obtain necessary information for resolution.
  • Identify potential compliance issues or risk factors requiring escalation.
  • Participate in case discussions, internal committee reviews, or external fair hearing preparation as assigned.
  • Document all activities, correspondence, and outcomes in the case management system with attention to detail and accuracy.
• Compliance & Quality
  • Ensure case handling meets all applicable federal and state regulatory requirements, including CMS, NCQA, and URAC.
  • Maintain confidentiality and protect member information in compliance with HIPAA regulations.
  • Identify opportunities for process improvements to enhance quality and efficiency.
• Team Collaboration
  • Serve as a resource to peers and administrators for routine case-related questions.
  • Maintain professional communication with members, providers, and internal stakeholders.
  • Participate in team meetings and contribute to continuous improvement initiatives.

Requirements

• High School Diploma or GED required; Associate’s Degree in Health Administration, Business, or related field preferred.
• 2 to 3 years of experience in healthcare operations, managed care, or grievance/appeals coordination.
• Knowledge of medical terminology, benefit interpretation, and regulatory processes preferred.
• Prior experience working with CMS, Medicaid, or state-regulated appeals processes preferred.

Skills

• Proficiency in Microsoft Office Suite (Word, Excel, Outlook, etc.).
• Strong attention to detail and organization.
• Excellent written and verbal communication.
• Ability to manage multiple priorities in a fast-paced environment.
• Strong analytical and problem-solving abilities.
• Customer service orientation with professional communication etiquette.

Benefits

• Flexible work solutions including remote options and hybrid work schedules.
• Competitive pay.
• Paid time off including holidays and volunteer events.
• Health insurance coverage for you and your dependents starting on Day 1.
• 401(k) retirement plan.
• Tuition reimbursement and more.