What are the responsibilities and job description for the Appeals and Grievance Specialist position at Well Sense Health Plan?
A company is looking for an Appeals and Grievance Specialist responsible for managing the resolution process of medical and pharmacy member appeals and grievances.Key Responsibilities : Manage member appeals and grievances, ensuring compliance with regulatory requirements and accreditation standardsCoordinate the investigation and resolution of member complaints in collaboration with clinical staff and internal departmentsPrepare and issue determination letters and reports to meet internal and external requirementsRequired Qualifications : Bachelor's degree in Health Care Administration or a related field, or equivalent experienceMinimum of 2 years' experience in a managed care organizationExperience with Medicare medical and pharmacy prior authorization processesKnowledge of CMS, MassHealth, and DHHS regulations is highly desirableExperience in conflict resolution is preferred
