Grievances & Appeals Senior Specialist

About the role

The Grievances & Appeals Senior Specialist is responsible for analyzing, investigating, and resolving grievances and pre‑service appeals across multiple lines of business. The role ensures timely case resolution in compliance with contractual and regulatory requirements while maintaining accurate documentation.

Key responsibilities

• Record, manage, and resolve cases submitted through the Complaint Tracking Module (CTM) and ensure proper categorization.
• Document investigation chronology in the CMS database, applying contractual language and evidence of coverage.
• Identify root causes, collaborate with operational managers, and develop corrective action plans.
• Participate in CTM workgroups to review RCA and coordinate sustainable action plans.
• Validate and register pre‑service appeals on electronic platforms (Clinical, USA, Dental, SSBCI, Part B medication).
• Submit denied appeals to Independent Review Entities (IRE) or Independent Review Organizations (IRO) as required.
• Monitor CTM and appeals metrics to protect three‑star performance indicators.
• Oversee on‑call program, ensuring 24/7 availability and compliance with regulatory requirements.

Required profile

• Bachelor’s degree in Business Administration, Finance, Social Services, or Criminal Justice.
• Minimum four years of experience in research, auditing, or client/provider service, preferably in health‑care insurance.
• Advanced proficiency in English and Spanish (written and verbal).

Required skills

• Familiarity with HPMS, PMHS, Beacon Healthcare System, and TruCare.
• Experience using CMS databases and CTM platforms for case management.