Appeals and Grievances Specialist

The Intersect Group; Los Angeles (CA); Hybrid; USD 70,000 - 110,000; Full time

Job summary

The Intersect Group is seeking an Appeals and Grievances Specialist to join our healthcare administration team. This role focuses on managing and resolving insurance claims appeals and grievances, ensuring regulatory compliance and excellent customer service to policyholders.

You will review policies, gather medical records, and coordinate with providers and internal teams. The position supports a fully remote work arrangement with a monthly in-office day in Southern California, and requires

Qualifications

• Proven experience in handling insurance claims management with a focus on health or workers' compensation insurance.
• Strong understanding of commercial insurance policies, medical claims processing, and insurance regulation compliance.
• Proficiency in Microsoft Office Suite (Word, Excel) along with experience using insurance claims management software.
• Knowledge of medical terminology, CPT coding, ICD coding (including ICD-9), HCPCS codes, and medical documentation standards.
• Demonstrated ability in claims negotiation, claims adjudication, and handling insurance claims litigation processes.

Responsibilities

• Review policies to assess health, workers' comp, and disability appeals.
• Investigate incoming appeals and grievances through thorough claim dispute investigations.
• Gather documentation from providers, policyholders, and internal teams.
• Document case details in claims software and track progress.
• Negotiate claim resolutions using adjudication knowledge and coding standards.
• Ensure compliance with insurance regulations at all stages of the appeals process.
• Prepare detailed reports on appeal outcomes for management review.
• Collaborate with claims processors, legal teams, and external agencies to facilitate dispute resolution or litigation when necessary.
• Conduct data entry with precision to update claim statuses and maintain confidentiality.
• Stay updated on regulatory changes and industry best practices.

Skills

Claims management

Regulatory compliance

Medical terminology

Negotiation

Excel

Tools

Insurance claims software

Job description

Fully Remote | Southern California | 1 Day/Month In-Office

Job Overview

We are seeking a highly organized and detail-oriented Appeals and Grievances Specialist to join our healthcare administration team. In this role, you will be responsible for managing and resolving appeals and grievances related to insurance claims, ensuring compliance with regulatory standards, and providing exceptional customer service to policyholders. The ideal candidate will possess comprehensive knowledge of insurance claims management, medical terminology, and regulatory requirements, contributing to the integrity of our claims adjudication process. This position offers an opportunity to support our mission of delivering transparent, compliant, and patient-centered insurance services.

Duties

• Review and interpret insurance policies, including health, medical, workers' compensation, and disability coverage, to accurately assess appeals and grievances.
• Handle incoming appeals and grievances efficiently by conducting thorough investigations into claim disputes.
• Communicate with healthcare providers, policyholders, and internal teams to gather necessary documentation such as medical records, billing information, and supporting evidence.
• Utilize insurance claims management software and financial software to document case details meticulously and track resolution progress.
• Negotiate claim resolutions by applying knowledge of claims adjudication processes, CPT coding, ICD coding, HCPCS codes, and medical documentation standards.
• Ensure compliance with insurance regulation standards and regulatory requirements during all stages of the appeals process.
• Prepare detailed reports on appeal outcomes for management review and maintain organized filing systems for all case documentation.
• Collaborate with claims processors, legal teams, and external agencies to facilitate dispute resolution or litigation when necessary.
• Conduct data entry with precision to update claim statuses accurately while maintaining confidentiality of sensitive medical records.
• Stay informed about updates in insurance regulation, workers' compensation laws, and industry best practices to enhance process efficiency.

Qualifications

• Proven experience in handling insurance claims management with a focus on health or workers' compensation insurance.
• Strong understanding of commercial insurance policies, medical claims processing, and insurance regulation compliance.
• Proficiency in Microsoft Office Suite (Word, Excel) along with experience using insurance claims management software.
• Knowledge of medical terminology, CPT coding, ICD coding (including ICD-9), HCPCS codes, and medical documentation standards.
• Demonstrated ability in claims negotiation, claims adjudication, and handling insurance claims litigation processes.