Appeals and Grievance Specialist Overview • The Appeals and Grievance Specialist role involves handling complaints, appeals, and disputes from members and providers. • This position requires meticulous attention to detail and the ability to work independently. • The role supports compliance with NCQA, CMS, and state regulations. • Candidates will process appeals and grievances, ensuring accurate administration of benefits and clinical policy. • The position requires proficiency in technology and data entry tasks. • This is a contract role with a focus on clearing departmental backlog by year-end. • Candidates should possess excellent communication and problem-solving skills. • The role offers the opportunity to contribute to quality improvement and operational efficiency. Appeals and Grievance Specialist Key Responsibilities & Duties • Review and evaluate appeal and grievance requests to classify member and provider appeals. • Determine eligibility, benefits, and prior activity related to claims or services. • Conduct thorough investigations and obtain information from internal and external entities. • Prepare cases for medical and administrative review, detailing findings and resolutions. • Monitor pending reports and worklists to ensure regulatory timeframes are met. • Provide written responses to member and provider correspondence, addressing issues accurately. • Collaborate with departments and entities to ensure timely resolution of cases. • Identify areas for improvement and recommend solutions to management. • Perform administrative tasks such as data entry and duplicate review. Appeals and Grievance Specialist Job Requirements • Associate Degree in a related field required; Bachelor’s degree preferred. • Minimum of 3 years of professional experience, preferably in health industry or compliance. • Proficiency in MS Office applications, especially word processing and spreadsheets. • Exceptional verbal and written communication skills with error-free correspondence ability. • Strong problem-solving, analytical, and organizational skills. • Ability to work under pressure and deliver accurate, timely results. • Customer service experience and knowledge of managed care/compliance environments. • Attention to detail and the ability to work independently. • Technology-savvy with experience in data entry and administrative tasks.