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 phone queue work as assigned.
• Prepare complete and compliant case files, ensuring all required documentation is included.
• Track case progress and maintain compliance with turnaround times and documentation standards.
• Generate accurate and timely determination and acknowledgement letters.

Investigation and Resolution

• Collaborate with internal departments such as Claims, Medical Management, Legal, and Compliance to obtain necessary information for resolution.
• Identify potential compliance issues or risk factors requiring escalation.
• Participate in case discussions, internal committee reviews, or external fair hearing preparation as assigned.
• Document all activities, correspondence, and outcomes in the case management system with attention to detail and accuracy.

Compliance & Quality

• Ensure case handling meets all application federal and state regulatory requirements, including with CMS, NCQA, and URAC.
• Maintain confidentiality and protect member information in compliance with HIPPA regulations.
• Identify opportunities for process improvements to enhance quality and efficiency.

Team Collaboration

• Serve as a resource to peers and administrators for routine case-related questions. 
• Maintain professional communication with members, providers, and internal stakeholders. 
• Participate in team meetings and contribute to continuous improvement initiatives.

Education/Experience

• Associate’s Degree: in Health Administration, Business, or related field preferred
• High School Diploma/GES Required

Preferred Experience Level

• Knowledge of medical terminology, benefit interpretation, and regulatory processes preferred. Prior experience working with CMS, Medicaid, or state-regulated appeals processes preferred.
• 2 to 3 years experience in healthcare operations, managed care, or grievance/appeals coordination.

Other Skills

• Proficiency in Microsoft Office Suite (Word, Excel, Outlook, etc.).
• Strong attention to detail and organization.
• Excellent written and verbal communication.
• Ability to manage multiple priorities in a fast-paced environment.
• Strong analytical and problem-solving abilities.

• Customer service orientation with professional communication etiquette.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents starting Day 1, 401(k) retirement savings plan, tuition reimbursement, and more.

Why Join Us: Your career starts now. We are looking for the next generation of healthcare leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you are driven to make a difference, we want to hear from you.

About AmeriHealth Caritas

Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with over 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. Our services include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at http://www.amerihealthcaritas.com