Grievance & Appeals Specialist

Job title: Grievance & Appeals Specialist 

Location: Remote, CST or EST required

Type: Temporary

Summary:  This role combines the responsibilities of utilization review with grievance and appeals management to ensure compliance with healthcare regulations and promote quality patient care. The specialist will evaluate medical necessity, process appeals and grievances, and collaborate with providers, members, and regulatory agencies to support fair and efficient healthcare services.

Responsibilities:

• Review medical records and claims to assess the appropriateness and necessity of healthcare services.
• Ensure adherence to clinical guidelines, payer policies, and regulatory requirements.
• Collaborate with healthcare providers to facilitate prior authorizations, medical necessity reviews, and utilization management decisions.
• Monitor patient care to optimize resource utilization and prevent unnecessary treatments or hospitalizations.
• Document and report findings to ensure compliance with healthcare standards and payer requirements.
• Investigate, analyze, and resolve member and provider appeals and grievances related to denied claims, service authorizations, and coverage disputes.
• Communicate appeal determinations clearly and professionally to members, providers, and regulatory agencies.
• Ensure compliance with state, federal, and payer regulations, including Medicare, Medicaid, and commercial insurance policies.
• Maintain thorough documentation of all appeals and grievances for reporting and audit purposes.
• Identify trends and recommend process improvements to enhance member satisfaction and regulatory compliance.

Qualifications:

• Higher education in Healthcare Administration or related field preferred. 
• 2+ years of experience in utilization review, case management, or appeals/grievance processing in a healthcare, insurance, or managed care setting.
• Strong knowledge of medical necessity criteria.
• Familiarity with Medicare, Medicaid, and commercial insurance policies.
• Excellent analytical, problem-solving, and decision-making abilities.
• Strong written and verbal communication skills for professional interactions with members, providers, and regulatory agencies.
•  Proficiency in medical terminology, coding, and claims processing.
• Ability to work independently and meet regulatory deadlines.

Benefits through CGC:  Dental, Vision, STD and/or LTD, Voluntary Life & AD&D, Accident, Critical Illness, Hospital Indemnity, Health Advocate EAP, and Health Equity Commuter Benefits, ZayZoon, and 401k.

We are an equal opportunity employer and prohibit discrimination/harassment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws