Grievance and Appeals Representative 4

About the position

The Grievances & Appeals Representative 4 is responsible for managing client denials and concerns through comprehensive reviews of clinical documentation. This role involves determining the necessity of grievances or appeals and delivering final determinations based on specialized skills and collaboration with clinical teams. The representative also assists members via phone, reviews appeal cases, and resolves issues while overseeing administrative priorities and coordinating work activities.

Responsibilities

• Manage client denials and concerns through analytic reviews of clinical documentation.
• Determine if grievances, appeals, or further requests are warranted.
• Deliver final determinations based on trained skillsets and partnerships with clinical teams.
• Assist members via phone to support quality-related goals.
• Review level 1 appeals cases for accuracy before forwarding to CMS.
• Investigate and resolve member and practitioner issues.
• Coordinate work activities and monitor progress towards schedules and goals.
• Assume ownership of main processes, programs, or technologies.

Requirements

• Minimum 2+ years of Grievance & Appeals and/or customer service experience.
• Strong data entry skills.
• Intermediate experience with Microsoft Word and Excel.
• Experience in a production-driven environment.
• Ability to handle multiple projects and assignments as directed by management.
• Capacity to maintain confidentiality and work independently.
• Strong time management skills.

Nice-to-haves

• Associate or Bachelor's Degree.
• Experience with electronic inventory management.
• Ability to complete assigned cases in a specified time frame.
• Previous inbound call center or related customer service experience.
• CAS experience strongly preferred.
• MedHOK experience strongly preferred.
• Previous experience processing medical claims.

Benefits

• Medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off including company and personal holidays.
• Volunteer time off.
• Paid parental and caregiver leave.
• Short-term and long-term disability.
• Life insurance.