Grievance Specialist
Core
Investigate and resolve member grievances and Medicare Advantage appeals within regulatory timelines, ensuring accurate documentation and clear communication with vulnerable members.
Role type
Healthcare operations specialist (grievance/appeals)
Builds
Resolved member cases and improved grievance processes
Domain
US Healthcare / Medicare Advantage
Deliverable
client delivery
Required skills
Medicare Advantage appeals and grievances experience, healthcare insurance policies knowledge, investigative analysis, regulatory compliance, conflict resolution, documentation accuracy, stakeholder collaboration
Preferred skills
Bachelor's degree in healthcare or related field, claims process knowledge, complex case assessment, time management, independent work
Technologies
Multiple case management platforms and documentation systems
Responsibilities
Conduct thorough grievance investigations by reviewing case details and member records; Triage and categorize grievances accurately; Communicate with members via telephone and written correspondence; Document investigations and decisions across multiple systems; Ensure grievances are resolved within regulatory timelines; Identify recurring grievance themes to inform process improvements
Seniority
Individual Contributor