Grievance & Appeals Specialist, Robert Half

Robert Half

Location:
United States, Los Angeles

Category:
Health and Beauty

Contract Type:
Employment contract

Salary:

Not provided

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Job Description:

The Grievance & Appeals Specialist will be responsible for investigating, documenting, and resolving denied claims, complying with State/Federal laws, rules, and guidelines. The role offers excellent training and benefits.

Job Responsibility:

Investigate, document, and resolve denied claims in accordance with State/Federal laws, rules, and guidelines
Perform research to respond to inquiries and interpret plan/policy provisions
Write determination letters regarding the outcome of non-clinical reviews/claim denials and send to the applicable participant/provider
Research incoming correspondence related to claim denials and determine the necessary next steps
Assist with research to advise management on medical claims issues and assist with developing guidelines for use by examiners or Participant Services Representatives
Assist Appeals Coordinator with the preparation of Benefits Committee appeal cases
Develop guidelines for examiners to use in evaluating whether certain types of claims may require review and other medical claims issues
Work with legal counsel on cases as directed by Management
Provide guidance to Participant Services Representatives on calls regarding medical claims issues
Recommend changes to management on Health Plan language for medical benefits

Requirements:

Minimum of 2 years of experience as a Medical Claims Review Coordinator or in a similar role
Proficient in handling Medical Claims and Medical Appeals
Experience with EMR - Electronic Medical Records is mandatory
Strong knowledge of Basic Medical Terminology
Proven track record in handling Appeals and Medical Grievances
Excellent coordination and organization skills
Ability to work under pressure and meet deadlines
Strong attention to detail and problem-solving skills
Excellent communication and interpersonal skills
Ability to work independently and as part of a team
High level of integrity and professionalism

What we offer:

Excellent training and benefits
medical, vision, dental, and life and disability insurance
eligible to enroll in our company 401(k) plan

Additional Information:

Job Posted:
July 19, 2025

Employment Type:

Fulltime

Work Type:

On-site work

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Grievance & Appeals Specialist