Med Appeals and Grievance Specialist II (remote)

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Requirements:

• 1-9 years of experience in clinical and health insurance, varying by level.
• Managed care experience with a focus in Utilization Management, Prior Authorization, Claims, Case Management or Medical Appeals.
• An Associate’s Degree in a healthcare-related field or a Nursing Diploma.
• Active and unrestricted license to practice as an RN, PT, or LMSW in Arizona.

Responsibilities:

• Perform in-depth analysis and clinical review for member and provider appeals, grievances, and corrected claims.
• Respond to customer inquiries through written and verbal communication.
• Analyze medical records to determine the appropriateness of requests.
• Maintain accurate records and meet performance goals.
• Consult with internal and external entities to resolve inquiries.