Appeals & Grievance Case Resolution Specialist

Amerihealth Caritas•Tinicum Township, PA

About The Position

The Appeals & Grievance Case Resolution Specialist manages assigned member and/or provider appeals and grievance cases through the full case life cycle. Working under general supervision, the Specialist conducts intake, investigation, and documentation to support accurate and timely resolutions that comply with federal and state requirements and accreditation standards. The role serves as a liaison among members, providers, and internal departments, supporting the integrity of the appeals and grievance process and compliance with CMS, NCQA, URAC, and state regulatory requirements. Responsibilities include researching case documentation and applicable coverage or regulatory guidance; communicating with members, providers, and representatives to clarify appeal intent and obtain missing documentation; preparing compliant case files; monitoring case progress and deadlines; and generating determination and acknowledgement letters. The Specialist collaborates with internal teams, escalates potential compliance concerns, participates in case reviews or fair-hearing preparation when assigned, and records case activities and outcomes in the case management system. The role also supports quality improvement and provides routine case-related guidance to peers and administrators. AmeriHealth Caritas is a mission-driven health care organization headquartered in Newtown Square, with more than 30 years of experience. It provides managed care, pharmacy benefit and specialty pharmacy, behavioral health, and administrative services. Remote or hybrid associates must have reliable high-speed internet with a minimum of 50 Mbps download and 5 Mbps upload. Fully remote associates in states where reimbursement is required by contract, law, or regulation may submit for reimbursement.

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’s 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 gather missing documentation, including through incoming and outgoing calls and assigned phone queue work.
Prepare complete and compliant case files with all required documentation.
Track case progress and meet turnaround-time 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 to resolve cases.
Identify potential compliance issues or risk factors and escalate them as needed.
Participate in case discussions, internal committee reviews, or external fair-hearing preparation as assigned.
Document activities, correspondence, and outcomes in the case management system accurately and carefully.
Protect confidential member information and follow applicable privacy requirements.
Identify opportunities to improve process quality and efficiency.
Serve as a resource to peers and administrators for routine case-related questions.
Communicate professionally with members, providers, and internal stakeholders.
Participate in team meetings and contribute to continuous improvement initiatives.