Grievances & Appeals Representative
Core
Review clinical documentation to assess and determine the justification of client grievances, appeals, and additional requests, providing final determinations.
Role type
Senior IC Grievances & Appeals Representative
Builds
Final determinations on insurance claim appeals and grievances
Domain
Healthcare insurance / Medicare & Medicaid
Deliverable
production ML models | product features | dashboards & analysis | research | client delivery | infrastructure | physical/clinical work
Required skills
Clinical documentation review, case assignment and monitoring, task prioritization, Microsoft systems proficiency (Teams, SharePoint, Excel), high-volume inventory management
Preferred skills
Inbound call center experience, grievance and appeals processing, medical terminology, bilingual English/Spanish, Medicare experience
Technologies
Microsoft Teams, SharePoint, Excel
Responsibilities
Assign cases to team members for independent 2nd level review; Monitor and record case assignment numbers and distribution; Operate within guidelines to maintain quality standards while managing timelines; Adapt to evolving processes in a fast-paced environment
Seniority
Mid-level, hands-on IC