Lead Specialist, Appeals & Grievances

📋 Description

• Lead the submission, intervention, investigation, and resolution of appeals, grievances, and
• Train new employees and provide guidance to colleagues handling complex appeals, grievances, and
• Research and resolve escalated matters, including state complaints and high-profile or particularly
• Coordinate with claims leadership to assign work across the team and support efficient workload
• Investigate claims appeals and grievances using internal systems and supporting documentation to
• Request and review medical records, clinical notes, detailed bills, and other relevant

🎯 Requirements

• At least 3 years of managed care experience in a call center, appeals, or claims environment, or an
• Experience with health claims processing, including coordination of benefits, subrogation, and
• Experience handling Medicare and Medicaid claims denials and appeals, with knowledge of the
• Strong customer service skills and the ability to communicate professionally with members
• Ability to research claims issues, interpret supporting documentation, apply coverage and contract
• Strong organizational skills, attention to detail, and the ability to manage multiple cases and

🎁 Benefits

• Competitive compensation package.
• Competitive employee benefits package.
• Equal opportunity employment.
• Specific details regarding salary ranges, healthcare coverage, retirement plans, paid time off, and