Appeals and Grievance Specialist

A company is looking for an Appeals and Grievance Specialist responsible for managing the resolution process of medical and pharmacy member appeals and complaints.

Key Responsibilities :

Manage member appeals and grievances, ensuring compliance with regulatory requirements and accreditation standards

Coordinate with internal departments and external vendors to resolve member complaints and grievances

Prepare and issue appeal determination letters and documentation, ensuring quality and organization of records

Required Qualifications :

Bachelor's degree in Health Care Administration or related field, or equivalent experience

Minimum of 2 years' experience in a managed care organization

Experience with Medicare medical and / or pharmacy prior authorization and appeals processes

Knowledge of CMS, MassHealth, and DHHS contractual provisions and NCQA accreditation requirements

Conflict resolution experience is highly preferred