What are the responsibilities and job description for the Appeals Coordinator position at Gentis Solutions?
Appeals & Grievance Specialist II
Location: Irving, TX (100% Onsite)
Duration: 6-Month Contract-to-Hire
Pay Rate: $25 per hour w2 w/benefits
Schedule: Monday-Friday, Onsite
Work Location: Irving, TX 75039
Required Qualifications
- Minimum 3 years of customer service experience supporting Managed Care Health Plans
- Minimum 2 years of Appeals & Grievances experience within a Managed Care organization
- Experience researching and resolving complex member and provider issues
- Knowledge of:
- Benefit interpretation
- Claims review
- CPT and ICD coding
- Medicare and/or TRICARE regulations
- Strong analytical, written communication, and problem-solving skills
- Ability to work independently while managing multiple cases
Position Summary
The Appeals & Grievance Specialist II is responsible for independently investigating, researching, and resolving member and provider appeals, grievances, and complaints. This role ensures all cases are processed in compliance with CMS, TRICARE, and our client's Health Plan requirements while delivering timely, accurate resolutions that improve member satisfaction and support Medicare STAR ratings.
Key Responsibilities
- Research and resolve member and provider appeals, grievances, and complaints.
- Investigate claim denials, reconsiderations, and redetermination requests.
- Interpret health plan benefits, medical claims, CPT/ICD coding, and supporting documentation.
- Coordinate with internal departments to obtain information and implement appeal decisions.
- Prepare clear, professional written responses to members and providers.
- Ensure compliance with CMS, TRICARE, state, and federal regulatory requirements.
- Track, analyze, and trend appeals and grievance data.
- Identify root causes of recurring issues and recommend process improvements.
- Support operational excellence and initiatives that improve Medicare STAR ratings.
Ideal Background
- Managed Care Health Plan experience
- Medicare Advantage and/or TRICARE experience
- Appeals & Grievance case management
- Claims analysis and benefit interpretation
- Medical terminology and coding knowledge
- Strong attention to detail and regulatory compliance experience
Salary : $23 - $28