Remote Appeals & Grievances Specialist I

Network Health Administrative Services, LLC; Town of Brookfield (WI); Hybrid; USD 55,000 - 65,000; Full time

Job summary

Network Health Administrative Services, LLC seeks an Appeals and Grievance Specialist I in Wisconsin to review, investigate, and summarize appeals and grievances filed by members.

Position involves documenting investigations, collaborating with legal, communicating case status to members, and ensuring timely resolutions in compliance with regulations; requires strong communication and regulatory knowledge.

Qualifications

• Two years of experience in health insurance appeals or grievances.
• Experience with state and federal regulations such as Medicare/ERISA preferred.
• Excellent communication and ability to interpret insurance plans and regulations.
• Strong Word and Excel skills and ability to research regulations.

Responsibilities

• Fully reviews all appeals and grievances assigned and determines required supporting documentation.
• Compile and reconcile documentation; resolve discrepancies with internal departments or providers.
• Communicate with members on status; gather missing information and educate on the process.
• Investigate, summarize findings, present cases, and obtain resolution within legal timeframes.
• Document all aspects of investigation and notifications in the database and logs.
• Collaborate with the legal department for hearing requests and prepare required documentation.
• Prepare letters and summaries outlining determinations with rationale per regulations.
• Demonstrate commitment to Network Health's mission and values.
• Perform other duties as assigned.

Skills

Communication skills

Regulatory interpretation

Customer service mindset

Analytical thinking

Education

High School diploma or equivalent

Associates degree preferred

Tools

Microsoft Word

Microsoft Excel

Regulatory databases

Job description

Network Health Administrative Services, LLC seeks an Appeals and Grievance Specialist I in Wisconsin to review, investigate, and summarize appeals and grievances filed by members.

Position involves documenting investigations, collaborating with legal, communicating case status to members, and ensuring timely resolutions in compliance with regulations; requires strong communication and regulatory knowledge.