Grievance and Appeals Specialist

What You'll Do:

Serves as the primary point of contact for members, providers, and authorized representatives throughout the grievance or appeal process
Conducts outbound calls to explain the process, gather facts, request records, and clarify the issue under review
Communicates decisions verbally and in writing using clear, plain language that meets applicable readability and translation requirements
Handles escalated and sensitive contacts, including expedited appeals, executive or regulatory complaints, and Ombudsman inquiries, with professionalism and empathy
Represents Telligen at State Fair Hearings as assigned, including preparation of case summaries and evidence packets
Intakes, classifies, triages, investigates, and resolves grievances, appeals, and provider disputes
Identifies expedited and clinical cases for appropriate routing
Researches claims, authorizations, eligibility, benefit coverage, and contract language
Prepares complete case files for clinical review by nurses and medical directors
Effectuates overturned decisions in claims or utilization management systems
Resolves cases within applicable regulatory and contractual timeframes and maintains accurate, complete, audit-ready documentation in the grievance and appeals system
Collaborates with Utilization Management, Claims, Member Services, Provider Relations, Pharmacy, Quality, and Compliance to investigate issues and address root causes
Presents cases and trends at Grievance & Appeals Committee meetings
Escalates systemic issues, potential quality-of-care concerns, and suspected fraud, waste, or abuse to the appropriate team
Serves as a subject-matter resource
Develops, documents, and maintains desk-level procedures, workflows, letter templates, and job aids
Translates federal and state contract changes into updated procedures in partnership with Compliance
Analyzes grievance and appeal data to identify trends, bottlenecks, and repeat issues and recommend improvements
Develops and delivers training for new hires and partner departments
Supports internal audits, state reviews, and NCQA accreditation readiness, including preparation of case universes and corrective action plans

Required Skills and Experience:

Associate's degree in healthcare administration, business, or a related field, or equivalent work experience
At least 3 years of managed care experience in grievances and appeals, claims, utilization management, or member/provider services, including at least 1 year directly handling grievance or appeal cases
Working knowledge of Medicaid managed care grievance and appeal requirements, including 42 CFR 438 Subpart F, and State Fair Hearing processes
Experience writing formal correspondence to members or providers
Proficiency with Microsoft Word, Excel, and Outlook
Experience with applicable state Medicaid programs and managed care contracts

Preferred Skills and Experience:

Experience with applicable state Medicaid programs and managed care contracts
Experience writing procedures, building workflows, or leading a process improvement project
Familiarity with Medicare Part C appeals, NCQA standards, medical terminology, CPT, or ICD-10 coding
Experience training or mentoring peers