Grievance and Appeals Specialist

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Are you detail-oriented, compassionate, and ready to take your problem-solving skills to the next level? We’re looking for a Grievance and Appeals Specialist to help ensure fairness, compliance, and exceptional service in every case. This fully remote role is ideal for someone with experience in claims and Medicare regulations who thrives in a fast-paced, collaborative environment.

What You’ll Do

As a Grievance and Appeals Specialist, you’ll play a vital role in ensuring timely, accurate, and compliant handling of Medicare Part D grievances, appeals, and member correspondence. Your work will directly impact members’ satisfaction and uphold regulatory and contractual standards.

Key Responsibilities:

Case Management & Investigations (50%)

• Log, track, and process grievances, appeals, and written correspondence.

• Review and research inquiries, supporting documentation, and benefit determinations.

• Compile and present case data to leadership for short-term solutions and long-term improvements.

• Collaborate across departments (claims, service, billing) to resolve complex issues.

Decision Support & Communication (40%)

• Analyze claims and plan policy to determine if they were adjudicated correctly.

• Work closely with supervisors and pharmacy teams for clinical input and final case decisions.

• Draft and proof accurate, clear letters and formal responses to members and providers.

• Conduct follow-up communications to ensure issues are fully resolved.

Compliance & Collaboration (10%)

• Stay current with CMS and PSERS policy changes through ongoing education.

• Support quality improvement initiatives and assist the PSERS leadership team.

• Uphold confidentiality and professionalism while working both independently and cross-functionally.

What You Bring

• Education: High school diploma or GED required

• Experience:

  • 2+ years of experience in claims processing or core healthcare operations

  • Strong knowledge of Medicare regulations, CMS guidelines, and healthcare policies

• Skills:

  • Critical thinking, research, and problem-solving skills

  • Clear and effective written and verbal communication

  • Tech-savvy with Microsoft Word, Excel, Outlook, and Teams

  • Strong organizational and time-management abilities

  • Comfortable working independently in a production-driven environment

Why Join Us?

• Remote Flexibility: Work from the comfort of your home while staying connected with a passionate and supportive team.

• Impactful Work: Play a key role in ensuring members receive fair and timely responses in critical healthcare situations.

• Growth Opportunity: Sharpen your knowledge of Medicare processes and contribute to continuous improvement initiatives.

Ready to make a difference in healthcare operations and member satisfaction?

Apply today to become a Grievance & Appeals Specialist and be a voice of resolution, fairness, and care.

HOURS: 37.5 hours per week between the hours of 8am and 5pm
LOCATION: Remote, but must be located in the state of Pennsylvania

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