Appeals Specialist

Hornet Staffing, Inc, a GEE Group company; Irving (TX); On-site; USD 55,000 - 75,000; Full time

Job summary

Hornet Staffing, Inc, a GEE Group company in Irving, TX seeks an experienced Appeals & Grievances Specialist II to support member and provider issue resolution within a leading health plan. You will research and resolve complaints, review denials, and interpret benefits, ensuring adherence to regulations and timely collaboration across teams.

Ideal candidates bring 3+ years in appeals and grievances within managed care, strong communication, and solid knowledge of CPT/ICD coding, with analytical

Qualifications

• 3+ years of Appeals & Grievance experience within a Managed Care Plan
• Strong customer service and communication skills
• Experience with claims review and benefit interpretation
• Knowledge of CPT and ICD coding
• Excellent analytical and problem-solving abilities

Responsibilities

• Research and resolve member and provider complaints, appeals, and grievances
• Review claim denials, reconsiderations, and redetermination requests
• Interpret benefits and analyze claims information
• Ensure compliance with state and federal healthcare regulations
• Collaborate with cross-functional teams for timely issue resolution
• Track, trend, and report appeal and grievance data
• Identify root causes and recommend process improvements

Skills

Appeals & Grievances

Managed Care

Job description

Are you an experienced healthcare professional with a background in Managed Care, Appeals & Grievances, and Claims Review? We are seeking a detail-oriented Appeals & Grievance Specialist II to join a leading health plan and support member and provider issue resolution.

Key Responsibilities:

Research and resolve member and provider complaints, appeals, and grievances

Review claim denials, reconsiderations, and redetermination requests

Interpret benefits and analyze claims information

Ensure compliance with state and federal healthcare regulations

Collaborate with cross-functional teams for timely issue resolution

Track, trend, and report appeal and grievance data

Identify root causes and recommend process improvements

Required Qualifications:

3+ years of Appeals & Grievance experience within a Managed Care Plan

Strong customer service and communication skills

Experience with claims review and benefit interpretation

Knowledge of CPT and ICD coding

Excellent analytical and problem-solving abilities

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