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 works under general supervision and serves as a key liaison between members, providers, and internal departments to resolve issues effectively.

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.
• 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 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.

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.

Education/Experience

• Associate’s Degree: in Health Administration, Business, or related field preferred
• High School Diploma/GES Required
• Preferred Experience Level: Knowledge of medical terminology, benefit interpretation, and regulatory processes preferred.
• 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

Our 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