Grievance and Appeals Case Specialist

The Jacobson Group; Rhode Island; Hybrid; USD 32,000 - 37,000; Full time

Benefits offered by this job

Medical insurance

Vision insurance

401(k) retirement savings plan

Job summary

The Jacobson Group is seeking a Case Specialist, Grievance and Appeals on a hybrid basis in Rhode Island. You will investigate and resolve member and provider complaints, manage benefits and administrative appeals, and maintain thorough case documentation.

The role requires Medicare experience within a managed care environment and strong communication skills. You will educate members about their plans, collaborate with internal teams on trend analysis and process improvements, and participate in

Qualifications

• 4+ years working with appeals and grievances in a managed care environment.
• Must reside within a commutable distance to Rhode Island and be willing to come into the office as needed.
• Medicare experience with appeals and grievances, customer service or claims.
• Strong written and verbal communication skills.

Responsibilities

• Investigate and resolve member and provider complaints, benefits appeals, and administrative appeals.
• Maintain detailed documentation of cases and follow up as necessary.
• Respond to inquiries via telephone and written communication, providing clear and accurate information.
• Educate members to improve their understanding of their healthcare plans.
• Identify and elevate potential quality of care issues for review.
• Collaborate with internal departments to analyze trends, identify root causes for appeals, and suggest procedural or policy changes.
• Prepare for departmental audits in anticipation of regulatory site visits.

Skills

Communication skills

Medicare experience

Appeals & grievances

Collaboration

Job description

The organization is seeking a dedicated and experienced Case Specialist, Grievance and Appeals to join their team on a hybrid basis. This role involves investigating and resolving member and provider complaints, benefits appeals, and administrative appeals for all company products. The successful candidate will maintain documentation of cases, respond to internal and external inquiries, assist members in understanding their plans through education, and collaborate with internal teams for trend analysis and process improvements. The candidate will also participate in departmental audits to prepare for regulatory site visits and identify potential quality of care issues, escalating concerns as appropriate. This position offers an excellent opportunity for a professional with Medicare experience and a strong background in appeals and grievances within a managed care environment.

Responsibilities:

• Investigate and resolve member and provider complaints, benefits appeals, and administrative appeals.
• Maintain detailed documentation of cases and follow up as necessary.
• Respond to inquiries via telephone and written communication, providing clear and accurate information.
• Educate members to improve their understanding of their healthcare plans.
• Identify and elevate potential quality of care issues for review.
• Collaborate with internal departments to analyze trends, identify root causes for appeals, and suggest procedural or policy changes.
• Prepare for departmental audits in anticipation of regulatory site visits.

Requirements:

• 4+ years working with appeals and grievances in a managed care environment
• Must reside within a commutable distance to Rhode Island and be willing to come into the office as needed
• Medicare experience with appeals and grievances, customer service or claims
• Strong written and verbal communication skills

Pay Range:

The anticipated pay for this position is $25.00 per hour. We understand salary is an important factor in a job search and encourage candidates to apply even if they feel that their desired compensation may fall outside of the listed range. The final pay for this position is determined based on several factors including but not limited to relevant experience, skills and certifications, education and training, geographic location, market conditions, and internal equity. We are committed to finding the right candidate for this role and are open to discussing how your unique qualifications align with our needs.

• Medical insurance
• Vision insurance
• 401(k) retirement savings plan

Equal Opportunity Employer:

The Jacobson Group is committed to fostering an inclusive and equitable workplace that reflects the diverse communities we serve. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status or any other protected characteristic as defined by applicable law. We believe that diversity of thought, background and experience strengthens our team and drives innovation. All employment decisions are based on qualifications, merit and business needs. If you require a reasonable accommodation to complete the application process or participate in an interview, please contact us at [e-mail] or [phone] to make a request.