Senior Grievance & Appeals Specialist — Complex Claims

CareSource Management Services; United States; Remote; USD 65,000 - 90,000; Full time

Job summary

CareSource Management Services is seeking a Grievance & Appeals Specialist III to collaborate with department leadership and handle processing and responses to claim appeals and disputes. The role provides subject matter expertise in clinical and code edit denials, supporting timely and accurate resolutions.

The ideal candidate will have 3+ years in healthcare customer service, claims, or compliance, including coding, and will excel in detailed analysis and cross-functional collaboration to meet

Qualifications

• High school diploma or equivalent required.
• Associates degree or equivalent experience preferred.
• 3+ years of healthcare customer service, claims, compliance or related experience required, including 1 year of coding experience.

Responsibilities

• Process and respond to claim appeals and disputes with subject matter expertise.
• Review appeals daily for validation and prepare for clinical review.
• Prepare clinical edit appeals for reviewer support and committee meetings.

Skills

Communication

Attention to detail

Time management

Customer service

Problem solving

Written communication

Language skills

Independent work

Teamwork

Critical thinking

Education

High school diploma

Associates degree

3+ years healthcare experience

Job description

CareSource Management Services is seeking a Grievance & Appeals Specialist III to collaborate with department leadership and handle processing and responses to claim appeals and disputes. The role provides subject matter expertise in clinical and code edit denials, supporting timely and accurate resolutions.

The ideal candidate will have 3+ years in healthcare customer service, claims, or compliance, including coding, and will excel in detailed analysis and cross-functional collaboration to meet