Non-Clinical Appeals Specialist

Job Summary

A company is looking for an Appeals and Grievances Non-Clinical Specialist (High Volume).

Key Responsibilities

• Manage case development and resolution for non-clinical cases, including claim denials and member/provider appeals
• Research issues, interpret regulations, and ensure compliance with regulatory timeframes
• Edit and finalize resolution letters while measuring productivity and quality against expectations

Required Qualifications

• Bachelor's degree from an accredited institution or relevant work experience
• Minimum of two (2) years of work experience in Managed Care or Health Insurance
• Experience in claims, customer service, or healthcare settings preferred
• Familiarity with care management systems such as CCMS, TruCare, or Hyland
• Demonstrated critical thinking and decision-making competencies