Appeals and Grievance Specialist

Appeals and Grievance Specialist II (Managed Care) Irving, TX | 12-Week Contract

Location: Irving, TX Job Type: 12-Week Contract Company: Sigma Inc. Schedule: MondayFriday | 8-Hour Shifts

Join Our Team as an Appeals and Grievance Specialist II!

Sigma Inc. is seeking an experienced Appeals and Grievance Specialist II to join our healthcare team in Irving, TX. This role is ideal for professionals with Managed Care, Medicare Appeals & Grievances, Claims Review, Medical Terminology, and Healthcare Customer Service experience.

If you have a strong background in appeals processing, grievance resolution, claims analysis, Medicare regulations, HIPAA compliance, and provider/member communication, we'd like to hear from you!

Key Responsibilities

• Investigate, review, and resolve member and provider appeals, grievances, and complaints.
• Research claim denials, reconsiderations, and redetermination requests.
• Interpret member benefits, Medicare policies, CPT/ICD coding, and reimbursement guidelines.
• Analyze appeals and grievance data to identify trends and recommend process improvements.
• Prepare clear, accurate written correspondence and decision letters to members and providers.
• Collaborate with internal departments to ensure timely and compliant case resolution.
• Educate members and providers regarding appeal and grievance procedures and benefit coverage.
• Maintain HIPAA compliance while handling Protected Health Information (PHI).
• Generate reports using Microsoft Word and Excel.
• Participate in departmental meetings and continuous quality improvement initiatives.

Required Qualifications

• Minimum 3 years of customer service experience within a Managed Care Plan.
• Minimum 2 years of Appeals and Grievance experience in a Managed Care environment.
• Experience researching and resolving healthcare claims, appeals, and grievances.
• Knowledge of Managed Care, Medicare, Claims Processing, Appeals & Grievances, and healthcare regulations.
• Strong analytical, research, and problem-solving abilities.
• Excellent written and verbal communication skills.
• Good typing and professional letter-writing skills.
• Basic computer proficiency, including Microsoft Word and Excel.
• Ability to work independently while meeting strict deadlines.
• Excellent customer service and conflict resolution skills.

Preferred Qualifications

• Knowledge of CPT and ICD coding.
• Familiarity with Medicare-covered benefits, CMS, and TRICARE regulations.
• Experience with medical terminology.
• Experience analyzing appeals and grievance trends.
• Healthcare insurance or health plan experience.

Required Skills

• Appeals & Grievance Processing
• Managed Care
• Medicare
• Claims Review
• Claims Resolution
• Medical Terminology
• CPT Coding
• ICD Coding
• Healthcare Customer Service
• Research & Analysis
• HIPAA Compliance
• Provider Relations
• Member Services
• Microsoft Word
• Microsoft Excel
• Written Communication
• Letter Writing
• Conflict Resolution
• Time Management
• Data Analysis