Grievance & Appeals Specialist I

This is a fully remote position, open to applicants in Pennsylvania.

📋 Description

• Examine, investigate, and monitor member grievances, appeals, and disputes related to provider claims.

• Collaborate with the G&A Administrator and external legal counsel during state fair hearing processes.

• Authenticate, allocate, and finalize document folders and records for member grievances and complaints.

• Assess incoming grievances, appeals, and provider claim disputes to ensure they comply with ARS and ADHS/DBHS policies and procedures.

• Organize meetings with relevant parties for the appeal processes.

• Carry out grievance investigations through internal and external interviews and thorough examination of pertinent documentation.

• Compose investigative reports and Notices of Decision or Resolution.

• Offer technical support for Notices of Action.

• Review files for quarterly, annual, and ad-hoc audits.

• Oversee daily entries into the DBHS Office of Grievance and Appeals database.

• Collaborate with relevant departments to enhance the grievance and appeals procedures.

• Assist with Fair Hearings and provide education and training to company personnel and external providers.

• Execute other assigned responsibilities and adhere to all policies and standards.

⛳️ Requirements

• Bachelor’s degree or equivalent qualification in a related discipline.

• 2+ years of experience in behavioral health or physical health.

• 1-2 years of pertinent experience is required.

• Preference for candidates with experience in processing grievances and appeals.

• Certification from the Council on Licensure, Enforcement and Regulation (CLEAR) or an equivalent certification program approved by ADHS/DBHS; certification must be acquired within 6 months of hire.

• Familiarity with Arizona Revised Statutes (ARS) and Arizona Department of Health Services (ADHS) / Department of Behavioral Health Services (DBHS) policies and procedures.

• Capability to perform investigations through interviews, document reviews, and interpretation of legal authorities and policies.

• Competence in drafting investigative reports and Notices of Decision or Resolution that meet ADHS/DBHS standards.

🏝️ Benefits

• Competitive pay.

• Health insurance.

• 401K.

• Stock purchase plans.

• Tuition reimbursement.

• Paid time off plus holidays.

• Flexible work arrangements with options for remote, hybrid, field, or office work schedules.

• Additional forms of incentives may be included in total compensation.