Appeals and Grievance Specialist

Managing the resolution process for medical and pharmacy member appeals and grievances, the full-time remote Appeals and Grievance Specialist will ensure compliance with regulatory requirements and accreditation standards while coordinating with internal and external stakeholders. Key responsibilities: Executes member appeals and coordinates management of complaints and grievances across departments Ensures compliance with CMS, MassHealth, and DHHS directives while preparing and issuing appeal determination letters Investigates grievances related to quality of care and implements corrective action plans as needed Required qualifications: Bachelor's degree in Health Care Administration or a related field, or equivalent combination of education and experience Two or more years of experience in a managed care organization Experience with Medicare medical and/or pharmacy prior authorization processes Comprehensive knowledge of CMS, MassHealth, and DHHS contractual provisions Knowledge and experience in conflict resolution highly preferred