Appeals & Grievances Case Manager (Oregon)

Pyramid Consulting, Inc; Oregon; Remote; USD 37,000 - 41,000; Full time

Job summary

Pyramid Consulting, Inc. has an immediate opening for an Appeals & Grievances Case Manager (Oregon). This is a 12+ months contract located in Oregon with remote options.

The role focuses on investigating, coordinating, and resolving member complaints, grievances, and appeals in compliance with health plan and regulatory standards. The ideal candidate will bring 2+ years in Appeals/Grievances or Care Coordination, strong CMS/DMHC/NCQA knowledge, and experience reviewing medical records.

Qualifications

• 2+ years in Appeals, Grievances or Care Coordination in a health plan or TPA.
• 5+ years of Appeals & Grievances experience within a Health Plan or Managed Care organization.
• Strong understanding of CMS, DMHC, and NCQA regulatory standards.
• Experience handling: Member Appeals, Provider Appeals, Authorization Appeals, Benefit Determinations.
• Knowledge of: CMS, DMHC, NCQA, Medi-Cal, Commercial Health Plans.
• Experience reviewing medical records and clinical documentation.

Responsibilities

• Investigate, coordinate, and resolve member complaints, grievances, and appeals in compliance with health plan and regulatory standards.
• Ensure timely and fair resolutions, accurate documentation, and strong cross-functional collaboration.

Skills

Appeals

Grievances

Care Coordination

CMS standards

DMHC standards

NCQA standards

Medical records review

Job description

Immediate need for a talented Appeals & Grievances Case Manager (Oregon). This is a 12+ Months Contract opportunity with long-term potential and is located in Oregon (Remote).

Job ID:26-31019

Pay Range: $27 - $30/hour. Traveler benefits as per agency package. (Benefits vary by vendor and assignment.)

Key Responsibilities:

• We are seeking a detail-oriented Case Manager – Appeals & Grievances to investigate, coordinate, and resolve member complaints, grievances, and appeals in compliance with health plan and regulatory standards.
• This role ensures timely and fair resolutions, accurate documentation, and strong cross-functional collaboration.

Key Requirements and Technology Experience:

• 2+ years experience in Appeals, Grievances or Care Coordination in a health plan or TPA.
• Strong understanding of CMS, DMHC, and NCQA regulatory standards.
• 5+ years of Appeals & Grievances experience within a Health Plan or Managed Care organization
• Experience handling:
• Member Appeals
• Provider Appeals
• Authorization Appeals
• Benefit Determinations
• Knowledge of:
• CMS
• DMHC
• NCQA
• Medi-Cal
• Commercial Health Plans
• Experience reviewing medical records and clinical documentation

Our client is a leading Healthcare Industry and we are currently interviewing to fill this and other similar contract positions.

Pyramid Consulting, Inc. provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.