Claims Specialist

Grievance & Appeals Customer Service Representative
We are seeking a detail-oriented Grievance & Appeals Customer Service Representative to join the Enterprise Grievance & Appeals Department. This position is responsible for reviewing, researching, documenting, and resolving non-complex member and provider grievances and appeals while delivering professional, accurate, and timely customer service.
The ideal candidate has strong customer service, written communication, research, analytical, and problem-solving skills with the ability to manage sensitive healthcare-related concerns in a fast-paced, highly regulated environment.
Key Responsibilities
Review, research, and process pre-service and post-service grievances and appeals submitted by members, providers, regulatory agencies, and third parties.
Investigate issues involving claims, benefits, provider networks, quality of service, quality of care, and clinical/non-clinical services across HMO, PPO, POS, EPO, CDHP, and indemnity products.
Provide professional customer service and issue resolution, ensuring members and provider concerns are thoroughly researched, documented, and addressed within required timeframes.
Analyze claims history, account information, medical records, correspondence, and supporting documentation to determine appropriate next steps.
Prepare clear, accurate, and professional written grievance and appeal determination letters using customer-friendly language.
Utilize established guidelines and review tools to approve eligible non-complex cases or escalate appropriate cases to nursing, medical, legal, or management teams for further review.
Maintain accurate and complete case documentation while adhering to strict regulatory accreditation, privacy, and departmental requirements, , including applicable URAC and NCQA standards.
Serve as a liaison between Grievances & Appeals, Medical Management, Claims, Legal, Service Operations, and other internal departments to facilitate timely case resolution.
Qualifications
High School Diploma or GED required.
Previous experience in customer service, healthcare, health insurance, claims, grievances and appeals, or a related administrative environment preferred.
Strong business writing and written communication skills with the ability to explain complex information clearly and professionally.
Strong research, analytical, problem-solving, organizational, and interpersonal skills.
Ability to work with confidential members, provider, claims, and medical information.
Ideal Candidate
The successful candidate will be a customer-focused, analytical, and highly organized professional who can investigate concerns, communicate effectively with members and providers, manage sensitive information, and produce accurate written responses while meeting strict quality and compliance standards.

Work arrangement
Yes