Appeals And Grievance Specialist

Specialist, Appeals & Grievances

Responsible for reviewing and resolving member and provider complaints and communicating resolutions.

Key Responsibilities:

• Conduct comprehensive research and resolve appeals, disputes, grievances, and complaints.
• Use internal systems to determine outcomes of claims appeals and grievances.
• Review medical records and billing details to formulate conclusions.
• Ensure timely and appropriate responses per state.
• Prepare summaries and correspondence; document findings and trends.
• Communicate with members and providers via written and verbal channels.
• Apply contract language and benefits knowledge to case reviews.

Qualifications:

• Education: High School Diploma or equivalent
• Experience:
  • Minimum 2 years in managed care (call center, appeals, or claims)
  • Experience in health claims processing, coordination of benefits, and eligibility
  • Familiarity with Medicaid and Medicare regulations
• Strong written and verbal communication skills
• Ability to work fully remote, equipment provided

Pay and Benefits

The pay range for this position is $18.00 - $22.00/hr.

Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following:

Medical, dental & vision Critical Illness, Accident, and Hospital 401(k) Retirement Plan Pre-tax and Roth post-tax contributions available Life Insurance (Voluntary Life & AD&D for the employee and dependents) Short and long-term disability Health Spending Account (HSA) Transportation benefits Employee Assistance Program Time Off/Leave (PTO, Vacation or Sick Leave)

Workplace Type

This is a fully remote position.

Application Deadline

This position is anticipated to close on Oct 17, 2025.