Appeals and Grievance Specialist

Appeals and Grievance Specialist II

Location: Irving, TX 75039

Pay range: $32-33/hr

Schedule: Monday-Friday

3 months contract to start

Position Summary:

We are seeking an experienced Appeals and Grievance Specialist II to join our team onsite in Irving, TX. This role is responsible for independently researching, investigating, and resolving member and provider appeals, grievances, complaints, and claim denials while ensuring compliance with CMS, Medicare, TRICARE, HIPAA, and applicable state and federal regulations.

The ideal candidate has prior experience working within a Managed Care Health Plan and possesses strong analytical, communication, and customer service skills.

Responsibilities

• Review and resolve member and provider appeals and grievances.
• Investigate claim denials, reconsiderations, and redeterminations.
• Interpret health plan benefits and claims.
• Review CPT and ICD coding as applicable.
• Communicate appeal decisions to members and providers.
• Prepare professional correspondence and determination letters.
• Analyze trends and prepare grievance reporting.
• Recommend process improvements to improve member satisfaction and Medicare STAR ratings.
• Maintain compliance with HIPAA and regulatory requirements.
• Collaborate with internal departments to resolve complex issues.
• Educate members and providers regarding the appeals and grievance process.
• Participate in departmental meetings and maintain documentation.

Education

• High School Diploma (proof of education required)
• Experience
• Minimum 3 years of customer service experience with Managed Care Plans
• Minimum 2 years of Appeals and Grievance experience with Managed Care Plans
• Preferred Knowledge
• Medicare
• CMS regulations
• TRICARE
• Claims review
• Medical terminology
• CPT and ICD coding
• HIPAA
• MS Word and Excel

Skills

• Strong analytical and research skills
• Excellent written and verbal communication
• Letter writing
• Conflict resolution
• Time management
• Customer service
• Ability to work independently and prioritize multiple assignments

Dexian stands at the forefront of Talent + Technology solutions with a presence spanning more than 70 locations worldwide and a team exceeding 10,000 professionals. As one of the largest technology and professional staffing companies and one of the largest minority-owned staffing companies in the United States, Dexian combines over 30 years of industry expertise with cutting-edge technologies to deliver comprehensive global services and support.

Dexian connects the right talent and the right technology with the right organizations to deliver trajectory-changing results that help everyone achieve their ambitions and goals.To learn more, please visit https://dexian.com/.

Dexian is an Equal Opportunity Employer that recruits and hires qualified candidates without regard to race, religion, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status.