Appeals & Grievance Specialist 

Schedule

• Monday – Friday

• Onsite Position

Position Summary

The Appeals & Grievance Specialist II is responsible for independently researching, reviewing, and resolving member and provider inquiries, complaints, appeals, and grievances. This role requires a strong understanding of health plan benefits, claims processing, CPT and ICD coding, and applicable state and federal regulations governing appeals and grievance processes.

The specialist ensures timely and accurate resolution of member and provider concerns while maintaining compliance with Medicare, Medicaid, TRICARE, and other regulatory requirements. This position works collaboratively with internal departments and external review organizations to facilitate appeal and grievance resolutions, identify trends, and recommend process improvements that enhance member satisfaction, operational efficiency, and quality outcomes.

Key Responsibilities

• Independently investigate, research, and resolve member and provider appeals, grievances, complaints, and inquiries.

• Review claim denials, reconsideration requests, and redetermination requests to determine appropriate resolution.

• Interpret health plan benefits, medical policies, and claims information while applying CPT, ICD, and other healthcare coding standards.

• Analyze information from multiple systems and sources to make informed and accurate determinations.

• Coordinate with clinical, claims, customer service, provider relations, and other internal departments to resolve complex issues.

• Prepare clear, accurate, and timely written correspondence communicating appeal and grievance decisions to members, providers, and authorized representatives.

• Ensure all appeals and grievances are processed within required regulatory timelines and organizational standards.

• Maintain compliance with all applicable federal, state, and regulatory requirements, including Medicare, Medicaid, TRICARE, and other governing agencies.

• Track, monitor, and document appeals and grievance activity in appropriate systems.

• Analyze appeals and grievance data to identify trends, recurring issues, and root causes of member and provider dissatisfaction.

• Prepare recurring reports and communicate findings to leadership and key stakeholders.

• Recommend process improvements that enhance operational efficiency, regulatory compliance, and customer satisfaction.

• Participate in quality improvement initiatives and special projects as assigned.

• Maintain confidentiality of protected health information (PHI) and comply with HIPAA regulations.

Minimum Qualifications

Education

• High school diploma or equivalent required.

• Proof of education must be provided.

Experience

• Minimum of three (3) years of customer service experience within a managed care health plan.

• Minimum of two (2) years of appeals and grievance experience within a managed care environment.

• Experience interpreting healthcare benefits, medical claims, and regulatory requirements.

• Experience working with CPT and ICD coding preferred.

Knowledge, Skills & Abilities

• Strong knowledge of managed care operations, claims processing, and health plan benefits.

• Understanding of Medicare, Medicaid, TRICARE, and other regulatory guidelines governing appeals and grievances.

• Knowledge of CPT, ICD, and healthcare terminology.

• Excellent analytical, critical thinking, and problem-solving skills.

• Strong written and verbal communication skills.

• Ability to independently prioritize workload and meet strict regulatory deadlines.

• Proficiency with Microsoft Office and healthcare information systems.

• Strong organizational skills with exceptional attention to detail.

• Ability to work collaboratively across multiple departments while managing confidential information.

• Commitment to delivering exceptional customer service and maintaining regulatory compliance.