Remote Appeals & Grievances Case Manager – Health Plan

Pyramid Consulting, Inc; Oregon; Remoto; USD 37.000 - 41.000; Tempo pieno

Descrizione del lavoro

Pyramid Consulting, Inc. has an immediate opening for an Appeals & Grievances Case Manager (Oregon). This is a 12+ months contract located in Oregon with remote options.

The role focuses on investigating, coordinating, and resolving member complaints, grievances, and appeals in compliance with health plan and regulatory standards. The ideal candidate will bring 2+ years in Appeals/Grievances or Care Coordination, strong CMS/DMHC/NCQA knowledge, and experience reviewing medical records.

Competenze

• 2+ years in Appeals, Grievances or Care Coordination in a health plan or TPA.
• 5+ years of Appeals & Grievances experience within a Health Plan or Managed Care organization.
• Strong understanding of CMS, DMHC, and NCQA regulatory standards.
• Experience handling: Member Appeals, Provider Appeals, Authorization Appeals, Benefit Determinations.
• Knowledge of: CMS, DMHC, NCQA, Medi-Cal, Commercial Health Plans.
• Experience reviewing medical records and clinical documentation.

Mansioni

• Investigate, coordinate, and resolve member complaints, grievances, and appeals in compliance with health plan and regulatory standards.
• Ensure timely and fair resolutions, accurate documentation, and strong cross-functional collaboration.

Conoscenze

Appeals

Grievances

Care Coordination

CMS standards

DMHC standards

NCQA standards

Medical records review

Descrizione del lavoro

Pyramid Consulting, Inc. has an immediate opening for an Appeals & Grievances Case Manager (Oregon). This is a 12+ months contract located in Oregon with remote options.

The role focuses on investigating, coordinating, and resolving member complaints, grievances, and appeals in compliance with health plan and regulatory standards. The ideal candidate will bring 2+ years in Appeals/Grievances or Care Coordination, strong CMS/DMHC/NCQA knowledge, and experience reviewing medical records.