Grievance & Appeals Specialist I
About The Position
Our Grievance & Appeals Specialist I act as the primary investigator for member appeals and grievances including analyzing, researching, and managing inventories. Responding to member/provider requests within regulatory requirements and plan policy. We're looking for Grievance & Appeals Specialist I with: Required Experience: 3 years’ health industry or related experience What a day of a Grievance & Appeals Specialist I would look like: Ensure cases are accurately classified and categorized. Prepare comprehensive case histories for presentation and consideration at committee meetings and audits. Determines if additional information or documentation is needed to make appropriate decisions. Interpret and apply business rules, policies and contract. Prepare appeal cases to send to an independent specialty reviewer. Present appeal case information to a multi-department committee.
Requirements
- 3 years’ health industry or related experience
- Good verbal and written communication skills
- Medical terminology
- Familiar with ICD10 and CPT coding
- Experience with Individual and Group Contract language
Nice To Haves
- Customer Service or Claims processing experience preferred
Responsibilities
- Ensure cases are accurately classified and categorized.
- Prepare comprehensive case histories for presentation and consideration at committee meetings and audits.
- Determines if additional information or documentation is needed to make appropriate decisions.
- Interpret and apply business rules, policies and contract.
- Prepare appeal cases to send to an independent specialty reviewer.
- Present appeal case information to a multi-department committee.
Benefits
- paid time off
- paid holidays
- community service and self-care days
- medical/dental/vision/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
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
No Education Listed
