Job Description

Grievance & Appeals Specialist

Location: Remote in Texas and South Carolina
Duration: 6 Months
Pay Range: $30 per hour.

Position Overview

The Appeals & Grievance Specialist is responsible for processing, analyzing, and responding to member appeals and grievances in compliance with regulatory, accreditation, and contractual requirements. This role involves researching complex cases, drafting detailed and accurate correspondence, and collaborating with internal and external stakeholders to ensure timely and compliant case resolution.

The ideal candidate will possess strong analytical, writing, and communication skills, with the ability to manage a high workload in a fast-paced environment while maintaining attention to detail and accuracy.

Key Responsibilities

• Process and manage appeals and grievances in accordance with federal, state, and accreditation guidelines (Medicare, Medicaid, CMS).

• Conduct thorough research and analysis to evaluate and respond to member and provider inquiries.

• Draft clear, accurate, and compliant case correspondence including resolution letters and documentation.

• Communicate effectively with customers to obtain necessary information and provide status updates or final determinations.

• Ensure all documentation and responses adhere to quality assurance and compliance standards.

• Collaborate cross-functionally with departments including Claims, Member Services, and Clinical Operations.

• Manage multiple priorities and meet strict timelines for case resolution.

• Maintain confidentiality and professionalism when handling sensitive health information.

Top Required Skills & Experience

• Proven ability to manage a large volume of cases in a fast-paced environment.

• Strong computer proficiency; comfortable navigating multiple systems.

• Knowledge of health insurance and Medicare/CMS regulations.

• Excellent customer service and interpersonal communication skills.

Additional Required Skills

• Exceptional writing and letter composition abilities.

• Strong analytical and problem-solving skills.

• Effective research and data interpretation capabilities.

• Demonstrated multi-tasking and organizational abilities.

Preferred Skills & Experience

• Previous Appeals & Grievances or healthcare operations experience.

• Experience with claim analysis and regulatory classifications (appeals, grievances, organizational determinations).

• Familiarity with basic computer operations, including saving files, using Excel, and navigating multiple systems.

• Degree or coursework in Healthcare, English, Communications, or related field.

• Strong project management and documentation skills.

Education & Certifications

• • Required: High School Diploma or GED.

  • Preferred: Bachelor’s Degree in English, Communications, Healthcare Administration, or related field.