Grievances & Appeals Rep

Job Description

REQUIREMENTS

• Must reside in the central or eastern time zone
• 2+ years of customer service experience
• Proficient in Microsoft Word and Excel, as candidate will need to use Word letter templates and Excel for case tracking
• Experience in production environments and consistently meeting performance metrics
• Experience managing a high-volume workload across multiple software systems, ensuring thoroughly documented outcomes and minimal data entry error rates

Preferred :

• Associate or bachelor’s degree
• Prior Grievances and Appeals experience
• Experience in medical claims processing
• Previous inbound call center or related customer service experience
• Knowledge of medical terminology
• Prior experience with Medicaid or Medicare
• Experience with CAS, CRM, CGX, Pahub, RxNova, or Service Read Only

RESPONSIBILITIES

• Review and evaluate several cases per hour by identifying valid Medicaid and AIP (dual) grievances and appeals cases.
• Assess case priorities while processing in chronological order, ensuring you handle all cases within strict turnaround times ranging from 24 hours to 5 days.
• Conduct analytic reviews of clinical documentation to determine case validity, including investigative work to find the denial.
• Make outbound calls to members or providers to request documentation, clarify case details or address outstanding issues.
• Review and code cases, routing them to the appropriate queue while collaborating with leadership to maintain accuracy.
• Stay current with frequently changing mentor documents and workflows.
• Monitor multiple workstreams and adapt quickly to process changes.
• Communicate gaps or issues and seek guidance as needed.

Are you interested in this position?

Apply by clicking on the “Apply Now” button below!

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