Grievance and Appeals Specialist - LHB

Workday; United States; Remote; USD 25,000 - 47,000; Full time

Job summary

Workday is seeking a Grievance & Appeal Specialist to address appeals within required timeframes and ensure contractual obligations are met. The role centers on accurate claims handling and timely resolutions in a fast-paced healthcare environment.

You will maintain, revise, and implement Policies and Procedures to ensure compliance with regulatory standards. This remote position requires strong communication, confidentiality, and the ability to work independently within a national telecommute

Qualifications

• Minimum two years of medical claims experience in health insurance.
• Strong problem solving, critical thinking, and investigation skills.
• Proficient with MS Word, Excel, Outlook.
• Excellent verbal and written communication.
• Ability to work independently with minimal supervision.
• Maintain confidentiality and handle time-sensitive tasks.

Responsibilities

• Address and handle appeals within specified timeframes.
• Maintain, revise, and implement Policies and Procedures to ensure compliance with regulatory standards and contractual obligations.
• Collaborate with team members, providers, and staff as needed.
• Ensure timely and accurate processing of grievances and appeals.

Skills

Medical claims experience

Communication skills

Problem solving

Independence

Confidentiality

Education

High School Diploma or GED

Tools

MS Office

Job description

Job Summary

The primary responsibility of the Grievance & Appeal Specialist is to address and handle the appeals received within specified timeframes as required to meet contractual obligations. The Specialist is responsible for the maintenance, revision, and implementation of Policies and Procedures to ensure compliance with applicable regulatory standards and contractual obligations.

Required Job Qualifications

• High School Diploma or GED
• Minimum two years of medical claims experience in health insurance environment
• Thorough working knowledge of Medicare, CMS guidelines, plan policies, and claims determination
• Demonstrated problem solving skills, including critical thinking and investigation
• Proficient with MS Suite including Word, Excel, Outlook
• Ability to work in a fast-paced, customer service & production driven environment
• Excellent verbal and written communication skills
• Ability to work effectively with employees/members, providers, and differing levels of co-workers and all levels of staff
• Read and interpret documents, criteria, instructions, and policy & procedure manuals
• Apply common sense understanding to carry out instruction furnished in written, oral or diagram form; Evaluate problems, develop alternative solutions and identify trends and patterns
• Capable of working in an environment that requires organization and prioritization in order to address time sensitive assignments.
• Maintain high level of confidentiality, flexibility and willingness to learn new tasks.
• Work in a dynamic team-oriented environment.
• Work independently with minimal supervision or instruction.

Preferred Job Qualifications

Previous experience with core operations preferred (in an healthcare claims environment)

This is a Telecommute (Remote) role.

Remote employees must live within the continental United States , excluding Alaska, California, Hawaii or New York.

EEO Statement

We are an Equal Opportunity Employment employer dedicated to providing a welcoming environment where the unique differences of our employees are respected and valued. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other legally protected characteristics.

Pay Transparency Statement

From health and wellness benefits, 401(k) savings plan, pension plan, paid time off, paid parental leave, disability insurance, supplemental life insurance, employee assistance program, paid holidays, tuition reimbursement, plus other incentives, we offer a robust total rewards package for associates. The compensation offered will vary depending on your job-related skills, education, knowledge, and experience. This role aligns with an annual incentive bonus plan subject to the terms and the conditions of the plan.

Min to Max Range: $18.07 - $33.92 Exact compensation may vary based on skills, experience, and location.