Appeals and Grievances Representative, Specialist (...

Your Role   The Appeals and Grievances Non-Clinical team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints. The Appeals and Grievances Representative, Specialist will report to the Appeals and Grievances Supervisor. In this role you will be responsible for oversight of team reviewing, researching, and responding to incoming appeals and grievances within established compliance timeframes while working alongside Supervisor.  Your Work   In this role, you will: Assist with telephone inquiries regarding member appeals Have full understanding of applicable legislation/regulations Ensure departmental compliance Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process Review incoming appeals and grievances and determine area to assign case to or reroute if the issue does not meet appeal or grievance criteria Administer ongoing grievance tracking, trending, and reporting for assigned grievances Performs to standard department metrics based on established goals and objectives Provide coaching and feedback to coordinators when applicable as well as case corrections in a timely manner Manage your time independently to ensure that all job duties are completed in a timely manner Work in a collaborative manner with team to meet compliance metrics Your Knowledge and Experience   Requires a high school diploma or GED Requires a minimum of 7 years of experience Requires at least 6 years combined operations experience such as I&B, Claims, Customer Services, Regulatory Affairs; of which at least 2 years direct experience is in Appeals/Grievances, or similar combination Commercial Appeals and Grievances experience preferred Requires attention to detail, ability to multitask, proficient grammar and strong research skill Requires basic job knowledge of systems and procedures obtained through prior work experience or education Knowledge of Microsoft Office, specifically, Word and Excel (must be able to enter and manipulate data) Willing to work weekends and/or holidays depending on business needs  

Created: 2025-04-01