Grievance and Appeals Specialist

Our client is hiring a Grievance and Appeals Specialist! In this role you would be responsible for analyzing and resolving verbal and written claims and authorization appeals from providers while pursuing resolution of formal grievances from members. As part of a collaborative, high-volume centralized operations team servicing dozens of regional markets, you will evaluate case details, draft clear correspondence, and maintain strict compliance with regulatory standards to ensure optimal outcomes for both members and healthcare providers. Must have 2+ years of experience working in Grievance and Appeals and be open to working 8-5 CST.

salary: $22 - $23 per hour
shift: First
work hours: 8 AM - 5 PM
education: High School

Responsibilities

• Case Management & Resolution: Gather, analyze, and report on verbal and written member and provider complaints, grievances, and appeals. Maintain complete, accurate, and confidential files for each case.
• Communications & Correspondence: Draft professional, accurate response letters tailored to member and provider appeals, complaints, and grievances.
• Committee & Quality Support: Coordinate meeting logistics, schedules, and materials for the Grievance and Appeals Committee as needed. Support pay-for-performance programs through accurate data entry, tracking, organization, and information research.
• Quality Improvement Initiatives: Assist with HEDIS production functions, including data entry, outreach calls to provider offices, and detailed claims research.
• Administrative Operations: Manage high volumes of incoming documentation, including scanning, faxing, sorting, and archiving physical and digital mail.

Skills

• Medical Claims (2 years of experience is required)
• Verbal Communication
• Analytical Thinking
• Healthcare Regulations (2 years of experience is required)
• Written Communication

Qualifications

• Years of experience: 3 years
• Experience level: Experienced

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Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.

At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact View email address on randstadusa.com.

Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).

This posting is open for thirty (30) days.

It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.