Grievance & Appeals Specialists

Grievance & Appeals Specialists

Location: New York, NY (Hybrid/Onsite as applicable)
Pay: $24.00 - $35.00 per hour
Full-Time

We are seeking experienced Grievance & Appeals Coordinators to support the intake, investigation, processing, and resolution of member and provider grievances and appeals while ensuring compliance with CMS, Medicare, Medicaid, and New York State regulatory requirements.

Responsibilities

• Review, investigate, and process member and provider grievances and appeals in accordance with regulatory timelines.
• Maintain accurate case documentation and tracking logs.
• Coordinate with Medical Directors, Claims, Provider Relations, Pharmacy, and other internal departments to facilitate timely case resolution.
• Prepare written correspondence to members, providers, and regulatory agencies.
• Monitor appeal deadlines and ensure compliance with CMS, DOH, and contractual requirements.
• Assist with Fair Hearings, External Appeals, and Independent Review Entity (IRE) cases as needed.
• Analyze case information and escalate complex issues appropriately.
• Support audit readiness by maintaining complete and accurate records.
• Participate in quality improvement initiatives and process enhancements.

Qualifications

• Bachelor's degree in Healthcare, Human Services, Business Administration, or a related field preferred (or equivalent experience).
• Minimum 2 years of Grievance & Appeals experience in a Medicare and/or Medicaid Managed Care environment required.
• Strong knowledge of CMS, Medicare, Medicaid, and New York State regulatory requirements.
• Excellent written and verbal communication skills.
• Strong organizational and analytical abilities with attention to detail.
• Proficiency in Microsoft Office.
• Experience with FACETS is preferred.

Compensation & Benefits

• $24.00 - $35.00 per hour