Appeals & Grievances Case Manager (Oregon)

Pyramid Consulting Healthcare; United States; Remote; USD 37,000 - 41,000; Full time

Job summary

Pyramid Consulting, Inc. is seeking an Appeals & Grievances Case Manager for Oregon on a remote US basis. The contract is for 12+ months with potential for extension, and compensation is hourly.

The role requires handling member and provider appeals, including authorization determinations, with a strong emphasis on CMS, DMHC, NCQA standards and accurate medical record review.

Qualifications

• 2+ years experience 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.
• Knowledge of CMS, DMHC, and NCQA regulatory standards.
• Experience handling: Member Appeals, Provider Appeals, Authorization Appeals, Benefit Determinations.

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.

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 US (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.