Appeals Specialist

Grievance And Appeals Analyst I

The Grievance and Appeals Analyst I is responsible for the review, investigation, and resolution of member grievances and appeals within a managed-care health plan. Ensures all activities are conducted in compliance with regulatory requirements, including those established by the Centers for Medicare & Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA). Supports timely, accurate, and compliant resolution of member and provider complaints while maintaining a high standard of customer service and operational excellence.

To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to:

• Conducts comprehensive review, investigation, and resolution of member grievances, appeals, and complaints in accordance with CMS, NCQA, and state regulatory guidelines.
• Research and analyze claims, benefit plans, authorizations, and supporting documentation to determine appropriate outcomes.
• Ensures all cases are processed within mandated regulatory and internal timelines.
• Requests, reviews, and interprets medical records, provider documentation, and itemized bills as needed to support case determinations.
• Applies contract language, benefit structures, medical policies, and coverage guidelines to grievance and appeals decisions.
• Collaborates with internal departments (e.g., Medical Management, Provider Relations, Compliance) to ensure accurate and consistent resolutions.
• Identifies root causes of issues, including claims processing errors, system configuration discrepancies, or Provider billing concerns.
• Prepares clear, concise, and compliant written correspondence to members, providers, and authorized representatives outlining determinations.
• Documents all case activity, findings, and outcomes in accordance with audit and regulatory requirements.
• Tracks and reports trends in grievances and appeals to support quality improvement initiatives.
• Communicates with members and providers via written and verbal channels to obtain additional information or clarify case details.
• Meets or exceeds departmental productivity and quality performance standards.

Required Qualifications

• Minimum of 2 years of experience in managed care, healthcare appeals, grievances, or claims processing; or equivalent combination of education and experience.
• Working knowledge of Medicare and/or Medicaid regulations, including CMS guidelines for appeals and grievances.
• Understanding of NCQA standards related to member complaint and appeals processes.
• Experience reviewing claims, including eligibility, coordination of benefits (COB), and denial management.
• Strong analytical and problem-solving skills with attention to detail.
• Excellent written and verbal communication skills, with the ability to compose regulatory-compliant correspondence.
• Strong organizational and time management skills with the ability to manage multiple priorities and meet strict deadlines.
• Proficiency in Microsoft Office applications and relevant claims or case management systems.

Preferred Qualifications

• Experience working in a managed care organization supporting Medicaid, Medicare Advantage, or Marketplace plans.
• Familiarity with medical terminology, coding, and utilization management processes.
• Prior experience handling complex or escalated grievance and appeals cases.
• Background in a healthcare setting such as a hospital, provider office, or health plan operations.

Working Conditions

• The noise level in the work environment is usually moderate.
• Works in the field
• Interacts with patients, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Duties accomplished at the end of the day/month. Attendance/punctuality. Compliance with Company regulations. Safety and Security. Quality of work.

The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

I have read this job description and understand what is expected of me while I occupy this role.