Appeals And Grievance Specialist

TEKsystems
$20.00 - $23.00 / hr
life insurance, sick time, 401(k), retirement plan
United States, Wisconsin, Menasha
Mar 29, 2025
Job Description: The Appeals and Grievance Specialist I is responsible for conducting full and fair investigations of appeal and grievance cases from commercial, Medicare, and self-insured members or their authorized representatives. This role ensures timely closure of all assigned cases in compliance with applicable state and federal regulations, NCQA standards, and internal policies and procedures. Key Responsibilities: * Fully review all appeals and grievances assigned to determine appropriate supporting documentation needed. * Compile supporting documentation for the appeal process and resolve any discrepancies with internal departments or providers. * Communicate with members regarding the status of their appeals and perform necessary outreach to gather missing information. * Educate members on the appeal or grievance process to mitigate future issues. * Investigate, summarize findings, present cases, and obtain resolution from designated sources within legally required timeframes. * Accurately document all aspects of the investigation and resolution process in the Appeals and Grievance database. * Collaborate with the legal department regarding hearing requests before an Administrative Law Judge (ALJ) and prepare required documentation. * Prepare letters or written summaries to members, providers, and third parties outlining benefit determinations. Work Hours: 8am - 5pm (On-site for training; 1 day on-site after training) Additional Skills & Qualifications: * Minimum of two years of experience working for a health insurance carrier or similar environment, preferably in appeals and grievance, customer service, claims, utilization management, or compliance. * Prior experience with state and federal regulations such as Medicare, ERISA, and Office of Commissioner of Insurance regulations is preferred. * High school diploma required; Associate degree preferred. * Intermediate Microsoft Office skills, including Word, Outlook, and Excel. * Ability to apply state and federal regulations to administer the appeals and grievance process. * Ability to review and interpret member's Certificate of Coverage (COC), Evidence of Coverage, and Summary Plan Descriptions. Employee Value Proposition (EVP): * Hybrid work environment with flexibility after training. Pay and Benefits The pay range for this position is $20.00 - $23.00/hr. Eligibility requirements apply to some benefits and may depend on your job classification and length of employment. Benefits are subject to change and may be subject to specific elections, plan, or program terms. If eligible, the benefits available for this temporary role may include the following: * Medical, dental & vision * Critical Illness, Accident, and Hospital * 401(k) Retirement Plan - Pre-tax and Roth post-tax contributions available * Life Insurance (Voluntary Life & AD&D for the employee and dependents) * Short and long-term disability * Health Spending Account (HSA) * Transportation benefits * Employee Assistance Program * Time Off/Leave (PTO, Vacation or Sick Leave) Workplace Type This is a fully onsite position in Menasha,WI. Application Deadline This position is anticipated to close on Apr 11, 2025. About TEKsystems: We're partners in transformation. We help clients activate ideas and solutions to take advantage of a new world of opportunity. We are a team of 80,000 strong, working with over 6,000 clients, including 80% of the Fortune 500, across North America, Europe and Asia. As an industry leader in Full-Stack Technology Services, Talent Services, and real-world application, we work with progressive leaders to drive change. That's the power of true partnership. TEKsystems is an Allegis Group company. The company is an equal opportunity employer and will consider all applications without regards to race, sex, age, color, religion, national origin, veteran status, disability, sexual orientation, gender identity, genetic information or any characteristic protected by law.