Grievances & Appeals Rep - Medicaid Intake in United States at Jobgether

This position is posted by Jobgether on behalf of a partner company. We are currently looking for a Grievances & Appeals Rep - Medicaid Intake in United States.

This role is centered on high-volume case review and intake within a fast-paced Medicaid grievances and appeals environment, where accuracy, speed, and compliance are critical. You will evaluate clinical and administrative documentation to determine case validity and ensure appropriate routing within strict regulatory timelines. Acting as a key part of a resolution-focused team, you will help ensure members and providers receive timely, accurate outcomes for complex healthcare issues. The position requires strong analytical thinking, attention to detail, and the ability to manage multiple workflows simultaneously. You will also engage directly with members and providers to gather information, clarify case details, and resolve outstanding issues. This is a mission-driven operational role where your work directly supports access to care and fair resolution processes.

• Review and triage high volumes of Medicaid and dual (AIP) grievance and appeal cases, identifying validity and ensuring appropriate classification and routing.
• Analyze clinical and supporting documentation to assess case merit, investigate denial rationale, and ensure accurate case determination.
• Process and prioritize cases in chronological order while meeting strict turnaround requirements ranging from 24 hours to 5 days.
• Conduct outbound communication with members and providers to request documentation, clarify case details, and resolve missing or incomplete information.
• Code, document, and route cases accurately across multiple systems while maintaining compliance with established workflows and regulatory standards.
• Monitor multiple work queues simultaneously, adapting quickly to changing processes, priorities, and procedural updates.
• Collaborate with supervisors and team leads to address gaps, escalate issues, and maintain operational accuracy and efficiency.

• 2+ years of customer service or high-volume operational support experience in a fast-paced environment.
• Experience working in production-driven roles with performance metrics and strict turnaround expectations.
• Strong proficiency in Microsoft Word and Excel for documentation, templates, and case tracking activities.
• Ability to manage multiple systems and workflows simultaneously with high attention to detail and low error rates.
• Strong analytical and problem-solving skills, particularly in reviewing complex documentation and identifying case validity.
• Excellent written and verbal communication skills for interacting with members, providers, and internal teams.
• Ability to adapt quickly to changing processes, priorities, and procedural updates in a dynamic environment.
• Preferred experience in Medicaid/Medicare, claims processing, call centers, or grievance and appeals operations.
• Familiarity with medical terminology and healthcare administrative systems is highly valued.

• Competitive salary range of $40,000 to $52,300 USD per year (based on experience and location).
• Comprehensive healthcare coverage including medical, dental, and vision insurance.
• 401(k) retirement savings plan.
• Paid time off, holidays, and additional leave options including parental and caregiver leave.
• Short-term and long-term disability coverage and life insurance.
• Remote work environment with structured training and defined schedules.
• Employee assistance and wellbeing programs supporting physical, mental, and financial health.
• Opportunity to contribute to meaningful healthcare access and resolution outcomes for members.