Grievance and Appeals Specialist

This is a fully remote position, open to applicants in Alabama, +41 more states.

📋 Description

• Manage and resolve appeals received within designated timeframes to fulfill contractual responsibilities.

• Develop, update, and enforce policies and procedures.

• Ensure adherence to relevant regulatory standards and contractual commitments.

• Collaborate with employees/members, providers, colleagues, and staff across all levels.

• Analyze and interpret documents, criteria, instructions, and policy manuals.

• Assess issues, create alternative solutions, and recognize trends and patterns.

• Handle time-sensitive tasks through effective organization and prioritization.

• Operate autonomously with minimal oversight in a dynamic, team-focused setting.

⛳️ Requirements

• High School Diploma or GED.

• At least two years of experience with medical claims in a health insurance context.

• Comprehensive knowledge of Medicare, CMS guidelines, plan policies, and claims adjudication.

• Proven problem-solving abilities, including critical thinking and investigative skills.

• Proficiency in MS Office Suite, including Word, Excel, and Outlook.

• Capability to thrive in a fast-paced, customer-focused, and production-oriented environment.

• Exceptional verbal and written communication abilities.

• Skill in working effectively with employees/members, providers, various co-worker levels, and all staff tiers.

• Competence in reading and interpreting documents, criteria, instructions, and policy manuals.

• Ability to apply common-sense reasoning to written, oral, or diagrammatic instructions.

• Skill in assessing issues, developing alternative solutions, and identifying trends and patterns.

• Strong organizational and prioritization skills for meeting time-sensitive tasks.

• High degree of confidentiality, adaptability, and eagerness to learn new responsibilities.

• Capability to function in a dynamic, team-oriented environment.

• Ability to work independently with minimal guidance or instruction.

• Prior experience in core operations preferred within a healthcare claims setting.

• Remote employees must reside within the continental United States, excluding Alaska, California, Hawaii, and New York.

🏝️ Benefits

• Health and wellness benefits.

• 401(k) savings plan.

• Pension plan.

• Paid time off.

• Paid parental leave.

• Disability insurance.

• Supplemental life insurance.

• Employee assistance program.

• Paid holidays.

• Tuition reimbursement.

• Additional incentives.

• Annual incentive bonus plan.