Appeals and Grievance Specialist

Appeals and Grievance Specialist II Location : Irving, TX 75039 Pay range : $32-33/hr Schedule : Monday-Friday Contract length : 3 months Position Summary We are seeking an experienced Appeals and Grievance Specialist II to join our team onsite in Irving, TX. This role is responsible for independently researching, investigating, and resolving member and provider appeals, grievances, complaints, and claim denials while ensuring compliance with CMS, Medicare, TRICARE, HIPAA, and applicable state and federal regulations. The ideal candidate has prior experience working within a Managed Care Health Plan and possesses strong analytical, communication, and customer service skills. Responsibilities Review and resolve member and provider appeals and grievances. Investigate claim denials, reconsiderations, and redeterminations. Interpret health plan benefits and claims. Review CPT and ICD coding as applicable. Communicate appeal decisions to members and providers. Prepare professional correspondence and determination letters. Analyze trends and prepare grievance reporting. Recommend process improvements to improve member satisfaction and Medicare STAR ratings. Maintain compliance with HIPAA and regulatory requirements. Collaborate with internal departments to resolve complex issues. Educate members and providers regarding the appeals and grievance process. Participate in departmental meetings and maintain documentation. Education High School Diploma (proof of education required) Minimum 3 years of customer service experience with Managed Care Plans Minimum 2 years of Appeals and Grievance experience with Managed Care Plans Medicare CMS regulations TRICARE Claims review Medical terminology CPT and ICD coding HIPAA MS Word and Excel Skills Strong analytical and research skills Excellent written and verbal communication Letter writing Conflict resolution Time management Customer service Ability to work independently and prioritize multiple assignments Dexian is an Equal Opportunity Employer that recruits and hires qualified candidates without regard to race, religion, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status. #J-18808-Ljbffr