NEMT Grievances & Appeals Specialist
About The Position
The Grievances & Appeals Specialist is responsible for managing, investigating, and resolving member complaints, grievances, and appeals in compliance with client, state, and federal requirements. Reporting to the Quality Assurance Manager, this role plays a critical part in protecting member rights, identifying service gaps, and driving continuous quality improvement across MediDrive’s operations. The Specialist ensures all cases are handled timely, accurately, and in accordance with contractual turnaround times, while maintaining a strong focus on member advocacy, regulatory compliance, and service excellence.
Requirements
- High school diploma required; Associate or Bachelor’s degree preferred.
- Minimum of two (2) years of experience in grievance resolution, customer service, healthcare operations, NEMT, or managed care.
- Experience working in Medicaid or Medicare Advantage environments preferred.
- Strong knowledge of complaint resolution processes and regulatory turnaround requirements.
- Excellent written and verbal communication skills, including professional phone etiquette.
- Strong analytical and problem-solving abilities with attention to detail.
- Ability to manage a high volume of cases in a fast-paced environment.
- Proficiency in Microsoft Office Suite (Word, Excel, Outlook).
- Typing speed of 35+ words per minute with high accuracy.
- Ability to learn and navigate multiple systems efficiently.
- Ability to work independently while collaborating effectively within a cross-functional team environment.
Nice To Haves
- Medical front-office, case management, social work, or healthcare administrative experience preferred.
- Bilingual (English/Spanish or other languages) preferred.
Responsibilities
- Receive, log, and acknowledge grievances and appeals from members, providers, clients, and regulatory agencies.
- Conduct thorough investigations by collecting trip records, call recordings, provider documentation, GPS data, and relevant system notes.
- Analyze root causes of service failures and recommend corrective and preventive actions.
- Draft clear, compliant written responses to members and clients within required turnaround timeframes.
- Escalate urgent or high-risk matters to the Quality Assurance Manager and leadership as appropriate.
- Ensure all grievances and appeals are processed in accordance with Medicaid, Medicare Advantage, and client-specific contractual requirements.
- Monitor and track turnaround time compliance to avoid penalties or liquidated damages.
- Maintain accurate documentation within the Grievance & Appeals tracking system.
- Assist with internal audits, client audits, and regulatory reviews related to complaint resolution.
- Identify trends and provide reporting to support performance improvement initiatives.
- Partner with Operations, Network Development, Call Center, and Technology teams to resolve issues and implement sustainable solutions.
- Engage with transportation providers (TPs) to gather documentation and ensure corrective actions are completed.
- Coordinate with clients, government agencies, and legal/compliance departments when cases fall outside standard workflows.
- Monitor member trips when necessary to ensure real-time issue resolution and service recovery.
- Identify systemic issues impacting member experience and escalate patterns to leadership.
- Support quality improvement initiatives and contribute to policy and procedure enhancements.
- Participate in special projects and additional duties as assigned by the Quality Assurance Manager.
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
