Appeals & Grievance Case Resolution Specialist

Amerihealth Caritas•Tinicum Township, PA

About The Position

The Appeals & Grievance Case Resolution Specialist manages the full life cycle of assigned member and/or provider appeals and grievance cases. Working under general supervision, the Specialist handles case intake, investigation, documentation, and resolution in accordance with federal and state regulations and accreditation standards. The role liaises with members, providers, and internal departments to resolve issues and maintain compliance with CMS, NCQA, URAC, and state requirements. The Specialist researches case records, communicates with members and providers to clarify appeals and obtain documentation, prepares compliant case files, tracks deadlines, and creates determination and acknowledgement letters. The role collaborates with internal teams, identifies issues requiring escalation, documents case activity, and supports case discussions, committee reviews, or fair hearing preparation as assigned. It also contributes to quality, process improvement, and team collaboration.

Requirements

High school diploma or GED required.
Two to three years of experience in healthcare operations, managed care, or grievance/appeals coordination.
Proficiency in Microsoft Office Suite, including Word, Excel, and Outlook.
Strong attention to detail and organizational skills.
Excellent written and verbal communication skills.
Ability to manage multiple priorities in a fast-paced environment.
Strong analytical and problem-solving abilities.
Customer service orientation and professional communication etiquette.

Nice To Haves

Associate degree in Health Administration, Business, or a related field.
Knowledge of medical terminology, benefit interpretation, and regulatory processes.
Prior experience working with CMS, Medicaid, or state-regulated appeals processes.

Responsibilities

Research and analyze case documentation, including benefit coverage, prior authorizations, claims, and regulatory guidance.
Communicate with members, providers, or representatives to clarify appeal intent and obtain missing documentation, including through incoming calls, outgoing calls, and assigned phone queue work.
Prepare complete and compliant case files with all required documentation.
Track case progress and meet turnaround times and documentation standards.
Generate accurate and timely determination and acknowledgement letters.
Collaborate with Claims, Medical Management, Legal, Compliance, and other internal departments to obtain information needed for case resolution.
Identify potential compliance issues or risk factors requiring escalation.
Participate in case discussions, internal committee reviews, or external fair hearing preparation as assigned.
Document activities, correspondence, and outcomes accurately in the case management system.
Ensure case handling complies with applicable federal and state requirements, including CMS, NCQA, and URAC standards.
Maintain confidentiality and protect member information in accordance with HIPAA regulations.
Identify opportunities to improve process quality and efficiency.
Serve as a resource to peers and administrators for routine case-related questions.
Maintain professional communication with members, providers, and internal stakeholders.
Participate in team meetings and continuous improvement initiatives.