Appeals and Grievances Specialist

Providing essential support for claims activities, the full-time Appeals and Grievances Specialist will manage the resolution of member and provider complaints, ensuring compliance with CMS standards while working in a remote environment. Key responsibilities Facilitates comprehensive research and resolution of appeals, grievances, and complaints from members and providers Requests and reviews medical records and documentation to determine appropriate outcomes for claims appeals Prepares appeal summaries and correspondence, ensuring compliance with regulatory requirements and internal standards Required qualifications At least 2 years of managed care experience in a call center, appeals, and/or claims environment Health claims processing experience, including knowledge of Medicaid and Medicare claims denials and appeals Strong organizational and time management skills to manage multiple projects and deadlines Effective verbal and written communication skills Proficiency in Microsoft Office suite and applicable software programs