Position Title:
Appeal & Grievance Clinical Reviewer
Location:
Remote in AZ or surrounding state with compact license
Assignment Duration:
14 weeks
Looking for someone to start ASAP
- Key technologies: Medicare Medical Necessity Appeals and Escalations/Appeals and Grievances Area
- Nice to haves: Claims knowledge or experience. Know salesforce, onbase and HRP (any or all).
- Similar skill set may be utilization management
Description:
- Maintains a thorough understanding of Health Plan operations and business unit processes, workflows and system requirements, including, but not limited to, plan benefits as outlined in the Explanation of Coverage (EOC) documents, authorizations, referrals, network and non-network provider claims, and regulatory compliance.
- Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes.
- Participates in CMS and other audits and related activities as required.
- Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate decisions involving grievance and appeal determinations.
- Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each and every day.
- The position requires a full-time work schedule.
- Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.
- Perform all other duties as assigned.
Required Job Skills
- Working knowledge of CMS Managed Care Manual Chapter 13 - Beneficiary Grievances, Organization Determinations, and Appeals and CMS Prescription Drug Benefit Manual Chapter 18 - Part D Enrollee Grievances, Coverage Determinations, and Appeals, knowledge of healthcare billing and claims adjudication processes
- Familiarity with medical terminology, ICD, CPT, HCPCS, and DRG codes, accurate and efficient keyboarding skills, and the ability to work effectively with common office software.
- Math, communications and business skills normally demonstrated by a high school degree or equivalent.
Required Professional Competencies
- Demonstrated ability to evaluate and interpret medical records and health plan benefit documents to make appropriate benefit determinations.
- Must possess highly developed interpersonal skills and communications skills, with a strong customer service orientation.
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Spectraforce Technologies
Jan 17, 2026