Grievances & Appeals Specialist I
About The Position
The Grievance & Appeals Specialist I serves as the primary investigator for member appeals and grievances. The role involves analyzing, researching, and managing inventories, and responding to member and provider requests in accordance with regulatory requirements and plan policy. The specialist prepares and presents appeal case information for independent review, committee consideration, and audits. The stated pay range is $23.63 to $33.09. The position is eligible for an annual incentive bonus that varies based on company and employee performance. The employer offers paid time off and holidays, community service and self-care days, insurance coverage, retirement benefits, disability and life insurance, education reimbursement, an employee assistance plan, adoption assistance, and paid family leave. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
Requirements
- Three years of health industry or related experience.
- Good verbal and written communication skills.
- Knowledge of medical terminology.
- Familiarity with ICD-10 and CPT coding.
- Experience with Individual and Group Contract language.
Nice To Haves
- Customer service or claims processing experience.
Responsibilities
- Ensure cases are accurately classified and categorized.
- Prepare comprehensive case histories for presentation and consideration at committee meetings and audits.
- Determine whether additional information or documentation is needed to make appropriate decisions.
- Interpret and apply business rules, policies, and contracts.
- Prepare appeal cases to send to an independent specialty reviewer.
- Present appeal case information to a multi-department committee.
- Respond to member and provider requests within regulatory requirements and plan policy.
- Analyze, research, and manage case inventories.
Benefits
- Paid time off
- Paid holidays
- Community service and self-care days
- Medical, dental, vision, and pharmacy insurance
- 401(k) matching and non-contributory plan
- Life insurance
- Short- and long-term disability
- Education reimbursement
- Employee assistance plan (EAP)
- Adoption assistance program
- Paid family leave program
- Annual incentive bonus, variable depending on company and employee performance
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
No Education Listed
