Appeals & Grievance Case Resolution Specialist

Job Summary

The Appeals & Grievance Case Resolution Specialist is responsible for the full life cycle of assigned member and/or provider appeals and grievance cases. This role conducts case intake, investigation, and documentation to ensure 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, ensuring the integrity of the appeals and grievance process and compliance with CMS, NCQA, URAC, and state regulatory requirements.

Essential Functions

• 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 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.
• Investigate and resolve cases collaboratively 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.
• Ensure case handling meets all applicable federal and state regulatory requirements, including with 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.
• 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.

Education/Experience

• Associate’s Degree: in Health Administration, Business, or related field preferred
• High School Diploma/GES Required
• Prior experience working with CMS, Medicaid, or state-regulated appeals processes preferred
• 2 to 3 years experience in healthcare operations, managed care, or grievance/appeals coordination

Other 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

Comprehensive Benefits Package

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