Appeals & Grievance Case Resolution Spec

**Job Summary**

The Appeals & Grievance Case Resolution Specialist is responsible for the full life cycle of assigned member and/or provider appeals and grievance cases. Working under general supervision, this role conducts case intake, investigation, and documentation to ensure accurate and timely resolution consistent with federal state, and accreditation standards. The Specialist serves as a key liaison between members, providers, and internal departments to resolve issues effectively, ensuring the integrity of the appeals and grievance process and compliance with CMS, NCQA, URAC, and state regulatory requirements.

**Essential Functions**

**_Case Management_**

+ Research and analyze case documentation, including benefit coverage, prior authorizations, claims, and regulatory guidance.
+ Communicate with members, providers, or representative to clarify appeal intent and gather missing documentation including incoming calls, outgoing calls, and ph...