Appeals & Grievance Specialist

Position Summary

Our client is seeking an Appeals & Grievances Specialist to investigate, coordinate, and resolve member appeals and grievances while ensuring compliance with regulatory requirements and established timelines. This role requires strong analytical skills, attention to detail, and the ability to manage multiple priorities in a fast-paced healthcare environment.

Key Responsibilities

• Investigate and resolve member appeals, complaints, and grievances.
• Research issues related to claims, benefits, authorizations, billing, enrollment, and quality of care.
• Gather information from members, providers, medical groups, and internal departments.
• Ensure accurate documentation and timely case resolution.
• Draft member correspondence, including acknowledgment and resolution letters.
• Identify and escalate urgent, compliance, privacy, or quality-of-care concerns.

Qualifications

• A high school diploma or equivalent.
• 2+ years of experience in health insurance, appeals and grievances, or claims.
• Strong analytical, problem-solving, and communication skills.
• Proficiency with Microsoft Office, including Word and Excel.
• Experience with HMO plans, claims adjudication, referrals, authorizations, or regulatory compliance is strongly preferred.