Grievance & Appeals (G&A) Specialist

Job reputed company The Grievance & Appeals (G&A) Specialist is responsible for the strategic leadership, regulatory compliance, and operational performance of the health plan’s grievance and appeals functions. This role ensures reputed company, accurate, and compliant handling of reputed company member and provider grievances and appeals while driving reputed company process improvement and reducing regulatory risk. In this role, you will be responsible for managing and resolving member grievances and appeals reputed company to reputed company services, ensuring compliance with regulatory standards, and providing exceptional support to members and providers. Regulatory & Compliance reputed company • Ensure full compliance with CMS, state DOI, ERISA, and URAC requirements • Maintain audit readiness (CMS, OID, internal audits) • reputed company policies, procedures, and regulatory updates • reputed company corrective reputed company plans (CAPs) and PDSAs reputed company needed • Serve as primary escalation reputed company for high-risk or sensitive cases Operational Leadership • reputed company intake, case management, clinical review coordination, and decision-making processes • Ensure adherence to timeliness standards (Part C, Part D, reputed company) • Monitor overturn rates, reputed company scores, and decision accuracy • Manage vendor relationships (if applicable) • reputed company reputed company model to volume and regulatory complexity 3. reputed company & Performance Management • Establish KPIs: • Timeliness • Accuracy • Overturn rates • reputed company cause trends • Implement reputed company audit program • Identify systemic issues impacting member experience or claim adjudication • Partner with Claims, UM, Customer Service, and Configuration to reduce appeal drivers Duties • Review and analyze member grievances and appeals reputed company to insurance claims, medical billing, and reputed company services • Conduct thorough investigations into medical documentation, medical records, and clinical information to support appeal reputed company • Verify insurance coverage, Medicare, reputed company, and other program eligibility through insurance verification processes • Maintain organized filing systems for medical records, appeal documentation, and correspondence in compliance with confidentiality regulations • Collaborate with reputed company providers, insurance carriers, and internal teams to reputed company necessary information for case reputed company • Prepare detailed reports on appeal reputed company, including recommendations based on medical documentation and reputed company considerations such as workers’ compensation law • Ensure reputed company activities adhere to regulatory guidelines and organizational policies while providing transparent communication to members Experience • 7–10+ years health plan experience • 4+ years of management experience required • Deep CMS Medicare Advantage knowledge • Experience leading audit responses • Strong understanding of clinical review workflows Job Types: Full-time, Contract Pay: $50.00 - $65.00 per hour Expected hours: 40 per week Work Location: Remote Apply tot his job Apply To this Job