Grievance & Appeals Specialist for Members

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 38,000 - 48,000; Full time

Job summary

CommunityCare HMO Inc. is seeking a dedicated professional to manage written inquiries from members and guide grievances and appeals through all levels of the process. The role ensures compliance with federal, state, and accreditation requirements and maintains meticulous documentation.

The position requires strong communication skills, attention to detail, and the ability to coordinate across departments, CMS, and external entities as part of an efficient resolution workflow.

Qualifications

• Minimum high school diploma or equivalent with 5 years related experience.
• Associates degree with 1 year related experience preferred.

Responsibilities

• Researches member issues and prepares grievance and appeals information for each level of the appeal process.
• Receives and responds to member and/or provider written and oral complaints and requests per procedures.
• Interacts with various departments and CMS to resolve issues and ensure tracking accuracy in the GATS system.
• Notifies members/providers of decisions at each level and coordinates with relevant teams for authorization and payment when indicated.
• Prepares grievance and appeal files for audit and assists with CMS quarterly reports.

Skills

Customer service experience

Oral and written communication

Multitasking

Microsoft applications

Organized and detail oriented

Education

High school diploma or equivalent + 5 years related experience

Associates degree + 1 year related experience

Job description

CommunityCare HMO Inc. is seeking a dedicated professional to manage written inquiries from members and guide grievances and appeals through all levels of the process. The role ensures compliance with federal, state, and accreditation requirements and maintains meticulous documentation.

The position requires strong communication skills, attention to detail, and the ability to coordinate across departments, CMS, and external entities as part of an efficient resolution workflow.