Lead Specialist, Appeals & Grievances

JobgetherManaged care

Based in the United StatesFull-TimeLead

Salary not disclosed

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Job Details

Experience: At least 3 years of managed care experience in a call center, appeals, or claims environment, or an equivalent combination of relevant education and experience.
Required Skills: Microsoft Office

Have at least 3 years of managed care experience in a call center, appeals, or claims environment, or an equivalent combination of relevant education and experience.
Have experience with health claims processing, including coordination of benefits, subrogation, and eligibility criteria.
Have experience handling Medicare and Medicaid claims denials and appeals, with knowledge of applicable regulatory guidelines.
Demonstrate customer service skills and the ability to communicate professionally with members, providers, and other stakeholders.
Be able to research claims issues, interpret supporting documentation, apply coverage and contract provisions, and determine appropriate resolutions.
Have strong organizational skills, attention to detail, and the ability to manage multiple cases and competing deadlines.
Have excellent written and verbal communication skills, including the ability to prepare clear, accurate, regulation-compliant correspondence.
Have working knowledge of Microsoft Office and other relevant software applications.
Be able to guide colleagues, support new employee training, and manage complex cases.
Preferred: experience with members or providers in a managed care organization, particularly Medicaid, Medicare, Marketplace, or other government-sponsored healthcare programs.
Preferred: experience in a medical office or hospital setting.
Preferred: completion of a healthcare-related vocational program, such as medical coding, medical billing, or medical assisting.

Lead the submission, investigation, and resolution of complex appeals, grievances, and complaints from members, providers, and external agencies.
Train new employees and guide colleagues handling complex appeals, grievances, and claims issues.
Research and resolve escalated matters, including state complaints and high-profile cases.
Coordinate with claims leadership to assign work and support team workload management.
Investigate claims matters using internal systems and supporting documentation, including medical records, clinical notes, and bills.
Apply benefit provisions, contract language, coverage requirements, and review protocols to determine appropriate resolutions.
Prepare appeal summaries, dispute documentation, formal correspondence, and written responses.
Research claims guidelines, provider contracts, fee schedules, and system configurations to identify payment-error causes.
Maintain case documentation and tracking information for reporting, trend analysis, audits, and process improvements.
Communicate with members and providers by phone and in writing, and meet productivity standards while maintaining accuracy and compliance.

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