Lead Specialist, Appeals & Grievances

Jobgether; United States; On-site; USD 75,000 - 110,000; Full time

Benefits offered by this job

Competitive compensation package

Comprehensive benefits package

Equal opportunity employer

Job summary

Jobgether is seeking a Lead Specialist, Appeals & Grievances to oversee complex healthcare claims appeals, grievances, and complaints. You will act as a resource for colleagues, guiding challenging cases and distributing workloads across claims operations.

The role requires experience with Medicare/Medicaid and strong analytical, communication, and leadership skills to ensure accurate, timely, and compliant resolutions.

Qualifications

• At least 3 years of managed care experience in appeals or claims.
• Experience with Medicare/Medicaid denials and appeals.
• Strong written and verbal communication; professional tone.
• Ability to train and guide colleagues.

Responsibilities

• Lead the submission, intervention, investigation, and resolution of appeals, grievances, and complaints.
• Train new employees and guide colleagues handling complex issues.
• Investigate escalated matters incl. state complaints and high‑profile cases.
• Coordinate with claims leadership to assign work and manage workload.

Skills

Customer service

Analytical skills

Communication

Leadership

Organization

Time management

Claims processing knowledge

Regulatory compliance understanding

Education

Healthcare-related vocational program

Tools

Microsoft Office

Job description

As a Lead Specialist, Appeals & Grievances, you will oversee complex healthcare claims appeals, grievances, and complaints, ensuring that members and providers receive accurate, timely, and compliant resolutions. You will serve as a key resource for colleagues, providing guidance on challenging cases and supporting the effective distribution of team workloads. Working across claims operations and other business functions, you will investigate payment disputes, interpret coverage requirements, and identify the root causes of claims issues. Your expertise will help ensure adherence to Medicare, Medicaid, and other applicable regulatory standards. Through detailed documentation, clear communication, and careful case analysis, you will contribute to improved service quality and operational consistency. This role is ideal for an experienced managed care professional with strong analytical skills, sound judgment, and a commitment to member and provider satisfaction.

Accountabilities

• Lead the submission, intervention, investigation, and resolution of appeals, grievances, and complaints submitted by members, providers, and external agencies.
• Train new employees and provide guidance to colleagues handling complex appeals, grievances, and claims-related issues.
• Research and resolve escalated matters, including state complaints and high-profile or particularly complex cases.
• Coordinate with claims leadership to assign work across the team and support efficient workload management.
• Investigate claims appeals and grievances using internal systems and supporting documentation to determine appropriate outcomes.
• Request and review medical records, clinical notes, detailed bills, and other relevant documentation as needed.
• Apply benefit provisions, contract language, coverage requirements, and applicable review protocols to determine appropriate resolutions.
• Ensure that responses are accurate, appropriate, and delivered within required timelines in accordance with state and federal regulations and organizational guidelines.
• Prepare appeal summaries, dispute documentation, formal correspondence, and written responses to members, providers, and authorized representatives.
• Research claims processing guidelines, provider contracts, fee schedules, and system configurations to identify the root causes of payment errors.
• Review and resolve provider reconsideration requests, claims adjustment requests, and inquiries submitted by external agencies.
• Maintain accurate case documentation and tracking information to support reporting, trend analysis, audits, and process improvements.
• Prepare draft narratives, graphs, flowcharts, and other materials for presentations, audits, and operational reviews.
• Communicate with members and providers by phone and in writing to clarify issues and explain case outcomes.
• Meet departmental productivity standards while maintaining accuracy, quality, and compliance.

Requirements

• Relevant experience: At least 3 years of managed care experience in a call center, appeals, or claims environment, or an equivalent combination of relevant education and experience.
• Claims processing knowledge: Experience with health claims processing, including coordination of benefits, subrogation, and eligibility criteria.
• Medicare and Medicaid expertise: Experience handling Medicare and Medicaid claims denials and appeals, with knowledge of the regulatory guidelines governing appeals and denials.
• Customer service: Strong customer service skills and the ability to communicate professionally with members, providers, and other stakeholders.
• Analytical skills: Ability to research claims issues, interpret supporting documentation, apply coverage and contract provisions, and determine appropriate resolutions.
• Organization and time management: Strong organizational skills, attention to detail, and the ability to manage multiple cases and competing deadlines.
• Communication: Excellent written and verbal communication skills, including the ability to prepare clear, accurate, and regulation-compliant correspondence.
• Technical proficiency: Working knowledge of Microsoft Office and other relevant software applications.
• Leadership: Ability to provide guidance to colleagues, support new employee training, and help manage complex cases effectively.

Preferred Qualifications Include

• Experience working with members or providers in a managed care organization, particularly within Medicaid, Medicare, Marketplace, or other government-sponsored healthcare programs.
• Experience in a medical office or hospital setting.
• Completion of a healthcare-related vocational program, such as medical coding, medical billing, or medical assisting.

Benefits

• Competitive compensation package.
• Competitive employee benefits package.
• Equal opportunity employment.
• Specific details regarding salary ranges, healthcare coverage, retirement plans, paid time off, and remote or flexible work arrangements are not provided in the source description.