Appeals and Grievances Specialist

Facilitating the resolution of member and provider complaints, the full-time Appeals and Grievances Specialist will manage claims activities, ensuring compliance with CMS standards while working in a remote environment. Key responsibilities Conduct comprehensive research and resolution of appeals, grievances, and complaints from members and providers Request and review medical records and claims to determine appropriate outcomes and ensure timely responses Prepare appeal summaries and correspondence, documenting findings and trends as required Required qualifications At least 2 years of managed care experience in a call center, appeals, or claims environment Health claims processing experience, including knowledge of Medicaid and Medicare claims denials and appeals Strong organizational and time management skills to handle multiple projects and meet deadlines Effective verbal and written communication skills Proficiency in Microsoft Office suite and applicable software programs