Lead Specialist, Appeals & Grievances in United States at Jobgether

This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Lead Specialist, Appeals & Grievances based in the United States.

As a Lead Specialist, Appeals & Grievances, you will oversee complex healthcare claims appeals, grievances, and complaints, ensuring that members and providers receive accurate, timely, and compliant resolutions. You will serve as a key resource for colleagues, providing guidance on challenging cases and supporting the effective distribution of team workloads. Working across claims operations and other business functions, you will investigate payment disputes, interpret coverage requirements, and identify the root causes of claims issues. Your expertise will help ensure adherence to Medicare, Medicaid, and other applicable regulatory standards. Through detailed documentation, clear communication, and careful case analysis, you will contribute to improved service quality and operational consistency. This role is ideal for an experienced managed care professional with strong analytical skills, sound judgment, and a commitment to member and provider satisfaction.

As a lead resource for appeals and grievances, you will support the resolution of complex claims matters, guide team members, and ensure that decisions and communications meet regulatory and departmental requirements. Your responsibilities will include:

• Lead the submission, intervention, investigation, and resolution of appeals, grievances, and complaints submitted by members, providers, and external agencies.

• Train new employees and provide guidance to colleagues handling complex appeals, grievances, and claims-related issues.

• Research and resolve escalated matters, including state complaints and high-profile or particularly complex cases.

• Coordinate with claims leadership to assign work across the team and support efficient workload management.

• Investigate claims appeals and grievances using internal systems and supporting documentation to determine appropriate outcomes.

• Request and review medical records, clinical notes, detailed bills, and other relevant documentation as needed.

• Apply benefit provisions, contract language, coverage requirements, and applicable review protocols to determine appropriate resolutions.

• Ensure that responses are accurate, appropriate, and delivered within required timelines in accordance with state and federal regulations and organizational guidelines.

• Prepare appeal summaries, dispute documentation, formal correspondence, and written responses to members, providers, and authorized representatives.

• Research claims processing guidelines, provider contracts, fee schedules, and system configurations to identify the root causes of payment errors.

• Review and resolve provider reconsideration requests, claims adjustment requests, and inquiries submitted by external agencies.

• Maintain accurate case documentation and tracking information to support reporting, trend analysis, audits, and process improvements.

• Prepare draft narratives, graphs, flowcharts, and other materials for presentations, audits, and operational reviews.

• Communicate with members and providers by phone and in writing to clarify issues and explain case outcomes.

• Meet departmental productivity standards while maintaining accuracy, quality, and compliance.

Requirements:

The ideal candidate brings hands-on healthcare claims experience, a strong understanding of managed care regulations, and the ability to guide others through complex appeals and grievances. The following qualifications are required:

• Relevant 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.

• Claims processing knowledge: Experience with health claims processing, including coordination of benefits, subrogation, and eligibility criteria.

• Medicare and Medicaid expertise: Experience handling Medicare and Medicaid claims denials and appeals, with knowledge of the regulatory guidelines governing appeals and denials.

• Customer service: Strong customer service skills and the ability to communicate professionally with members, providers, and other stakeholders.

• Analytical skills: Ability to research claims issues, interpret supporting documentation, apply coverage and contract provisions, and determine appropriate resolutions.

• Organization and time management: Strong organizational skills, attention to detail, and the ability to manage multiple cases and competing deadlines.

• Communication: Excellent written and verbal communication skills, including the ability to prepare clear, accurate, and regulation-compliant correspondence.

• Technical proficiency: Working knowledge of Microsoft Office and other relevant software applications.

• Leadership: Ability to provide guidance to colleagues, support new employee training, and help manage complex cases effectively.

Preferred qualifications include:

• Experience working with members or providers in a managed care organization, particularly within Medicaid, Medicare, Marketplace, or other government-sponsored healthcare programs.

• Experience in a medical office or hospital setting.

• Completion of a healthcare-related vocational program, such as medical coding, medical billing, or medical assisting.

Benefits:

• Competitive compensation package.

• Competitive employee benefits package.

• Equal opportunity employment.

• Specific details regarding salary ranges, healthcare coverage, retirement plans, paid time off, and remote or flexible work arrangements are not provided in the source description.