Medical Appeals and Grievance Specialist II

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

📋 Description

• Tasked with leveraging clinical expertise and managed care knowledge to research, resolve, and address requests for member and provider appeals, grievances, reconsiderations, and corrected claims across all business lines, with a strong emphasis on privacy, precision, and adherence to all regulatory and compliance timelines.

• Identify, investigate, process, resolve, and respond to customer inquiries primarily through written and verbal communication.

• Handle a diverse and substantial volume of health insurance appeal-related correspondence on a daily basis.

• Review medical records and apply medical necessity criteria along with benefit plan requirements to assess the validity of appeal, grievance, and reconsideration requests.

• Keep comprehensive and accurate records in accordance with department policies.

• Meet established quality, quantity, and timeliness standards to fulfill individual and departmental performance objectives as outlined by departmental guidelines and mandated by State, Federal, and other accrediting bodies.

⛳️ Requirements

• 1 year of experience in clinical and health insurance or a related healthcare field.

• 3 years of experience in clinical and health insurance or a related healthcare field.

• 1 year of managed care experience with a concentration in Utilization Management (UM), Prior Authorization (PA), Claims, Case Management, and/or Medical Appeals and Grievances (MAG).

• 5 years of experience in clinical and health insurance or a related healthcare field.

• 2 years of managed care experience with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Case Management, and/or Medical Appeals and Grievances (MAG).

• 8 years of experience in clinical and health insurance or a related healthcare field.

• 3 years of satisfactory job performance in the managed care environment with a focus on Utilization Management (UM), Prior Authorization (PA), Claims, Case Management, and/or Medical Appeals and Grievances (MAG).

• Associate’s Degree in a healthcare-related field of study or a Nursing Diploma (applicable to all levels).

🏝️ Benefits

• Health insurance.

• 401(k) matching.

• Flexible work arrangements.

• Professional development opportunities.