Appeals & Grievance Case Resolution Specialist

Amerihealth Caritas • ,

10h

About The Position

The Appeals & Grievance Case Resolution Specialist manages the full life cycle of assigned member and/or provider appeals and grievance cases under general supervision. The role conducts intake, investigation, and documentation to ensure accurate and timely resolutions that comply with federal and state requirements and accreditation standards. The Specialist serves as a liaison among members, providers, and internal departments, supporting effective case resolution and the integrity of the appeals and grievance process.

Responsibilities include researching case documentation such as benefit coverage, prior authorizations, claims, and regulatory guidance; communicating with members, providers, or representatives to clarify appeal intent and obtain missing documentation; preparing complete case files; tracking progress and required turnaround times; and generating determination and acknowledgement letters. The Specialist collaborates with internal departments, identifies issues requiring escalation, participates in case discussions or fair-hearing preparation as assigned, and records case activities and outcomes in the case management system.

The role also supports regulatory compliance and confidentiality, contributes to process improvements, assists peers with routine case questions, maintains professional communication, and participates in team meetings and continuous improvement initiatives. The posting offers remote options and hybrid schedules; fully remote or hybrid associates need reliable high-speed internet with at least 50 Mbps download and 5 Mbps upload. Eligible fully remote associates may submit for reimbursement where service is required by contract, law, or regulation.

Requirements

• High school diploma or GED required.
• 2 to 3 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 incoming and outgoing calls and phone queue work as assigned.
• 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 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 meets applicable federal and state regulatory requirements, including CMS, NCQA, and URAC requirements.
• Maintain confidentiality and protect member information in compliance 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 contribute to continuous improvement initiatives.

Benefits

• Flexible work solutions, including remote options and hybrid work schedules.
• Competitive pay.
• Paid time off, including holidays and volunteer events.
• Health insurance coverage for associates and their dependents starting on Day 1.
• 401(k).
• Tuition reimbursement.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED