Grievance and Appeals Specialist

Telligen•Oak Brook, IL

3d•$62,000 - $75,000

About The Position

The Grievance and Appeals Specialist independently resolves member and provider grievances and appeals within applicable state Medicaid, federal, contractual, and accreditation timeframes. The role works directly with members, providers, and authorized representatives, and collaborates across departments to ensure fair, accurate, and well-documented outcomes. The specialist manages moderately complex cases, supports process improvement, and develops procedures and training materials. The position supports the Illinois Tailored Care Management Program, which helps individuals with complex health and social needs transition from nursing facilities and Specialized Mental Health Rehabilitation Facilities to community-based living through person-centered care management and coordinated support services.

Requirements

Associate's degree in healthcare administration, business, or a related field, or equivalent work experience.
At least 3 years of managed care experience in grievances and appeals, claims, utilization management, or member/provider services, including at least 1 year directly handling grievance or appeal cases.
Working knowledge of Medicaid managed care grievance and appeal requirements, including 42 CFR 438 Subpart F, and State Fair Hearing processes.
Experience writing formal correspondence to members or providers.
Proficiency with Microsoft Word, Excel, and Outlook.
Experience with applicable state Medicaid programs and managed care contracts.

Nice To Haves

Experience writing procedures, building workflows, or leading a process improvement project.
Familiarity with Medicare Part C appeals, NCQA standards, medical terminology, CPT, or ICD-10 coding.
Experience training or mentoring peers.

Responsibilities

Serve as the primary point of contact for members, providers, and authorized representatives throughout grievance and appeal processes.
Conduct outbound calls to explain processes, gather facts, request records, and clarify issues under review.
Communicate decisions verbally and in writing using clear, plain language that meets readability and translation requirements.
Handle escalated and sensitive contacts, including expedited appeals, executive or regulatory complaints, and Ombudsman inquiries.
Represent Telligen at State Fair Hearings as assigned, including preparing case summaries and evidence packets.
Intake, classify, triage, investigate, and resolve grievances, appeals, and provider disputes.
Identify expedited and clinical cases for appropriate routing.
Research claims, authorizations, eligibility, benefit coverage, and contract language.
Prepare complete case files for clinical review by nurses and medical directors.
Effectuate overturned decisions in claims or utilization management systems.
Resolve cases within regulatory and contractual timeframes and maintain complete, accurate, audit-ready documentation in the grievance and appeals system.
Collaborate with Utilization Management, Claims, Member Services, Provider Relations, Pharmacy, Quality, and Compliance to investigate issues and address root causes.
Present cases and trends at Grievance & Appeals Committee meetings.
Escalate systemic issues, potential quality-of-care concerns, and suspected fraud, waste, or abuse to the appropriate team.
Serve as a subject-matter resource.
Develop, document, and maintain desk-level procedures, workflows, letter templates, and job aids.
Translate federal and state contract changes into updated procedures in partnership with Compliance.
Analyze grievance and appeal data to identify trends, bottlenecks, and recurring issues, and recommend improvements.
Develop and deliver training for new hires and partner departments.
Support internal audits, state reviews, and NCQA accreditation readiness, including preparing case universes and corrective action plans.