Grievances & Appeals Specialist

About the role

The Grievances & Appeals Specialist is responsible for analyzing, investigating, and resolving member, provider, and insured grievances, dental pre‑service requests, and payment appeals in accordance with CMS regulations, OIC guidelines, and internal policies.

Key responsibilities

• Analyze, investigate, and respond to grievances, dental pre‑service, and payment appeals for MCS Classicare and MCS Life policyholders.
• Collaborate with internal departments, dental physician reviewers, delegated entities, and external suppliers to validate responses and identify root causes.
• Document cases using the Grievances & Appeals management platform and, when required, forward notifications to the Net Claim system.
• Handle case reconsiderations and member requests, ensuring compliance with CMS‑contracted Independent Review Entities and OIC regulations.
• Maintain accurate English case files, meeting timeliness requirements (24 hours for expedited, 30 calendar days for standard).
• Monitor metrics related to Appeals Timeliness and Appeals Review to avoid negative impact on performance scores.
• Provide required data to G&A analysts and supervisors for reporting purposes.

Required profile

• Strong knowledge of CMS regulations, Office of the Commissioner of Insurance (OIC) rules, and independent review processes.
• Excellent investigative and analytical abilities with attention to detail.
• Effective communication skills for verbal and written interaction with insureds, providers, and internal teams.
• Ability to work under strict deadlines and manage multiple cases simultaneously.

Required skills