Grievance & Appeals Claims Specialist - Denver Health Medical Plan (*Must Reside In Or Relocate To Colorado*)

We are recruiting for a motivated Grievance & Appeals Claims Specialist - Denver Health Medical Plan (*Must Reside In Or Relocate To Colorado*) to join our team!

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Department

Managed Care Administration

(*Must Reside In Or Relocate To Colorado*)

Job Summary

The Grievance & Appeals Claims Specialist is a key position responsible for handling and resolving client grievances and appeals regarding services and claims. This role ensures that all complaints are addressed promptly and accurately, maintaining compliance with regulatory standards and company policies. The specialist is an advocate for clients, working to resolve issues and improve overall satisfaction while safeguarding the integrity and efficiency of the organization.

Essential Functions:

• Handle and resolve incoming grievances and appeals in a timely and efficient manner (20%)
• Document all complaints, appeals, and resolutions accurately in the system. (20%)
• Conduct thorough investigations to gather necessary information for resolving appeals. (10%)
• Communicate effectively with clients, providers, and internal departments to resolve issues. (10%)
• Ensure compliance with regulatory standards and organizational policies. (10%)
• Collaborate with other departments to address systemic issues and prevent future grievances. (10%)
• Provide regular updates to management on the status of grievances and appeals. (10%)
• Analyze trends in claims grievances and appeals to identify areas for improvement. (10%)

Education:

• High School Diploma or GED required OR
• Associate's degree preferred

Work Experience:

• Associates degree and 1 year of claims, customer service, or grievance and appeals experience required OR
• 3 years of experience in the insurance industry, claims experience required OR
• 1 year of QNXT experience required

Licenses:
Knowledge, Skills and Abilities:

• Strong knowledge of regulatory requirements and insurance products.
• Excellent communication and interpersonal skills.
• Proven analytical and problem-solving abilities.
• Ability to handle sensitive and confidential information appropriately.
• Proficiency in using relevant software and database systems.
• Strong organizational and time-management skills.
• Understanding of grievance and appeals processes.
• Strong written and verbal communication skills.
• Attention to detail and accuracy.
• Ability to Ability to work independently and as part of a team.
• Ability to manage multiple tasks and meet deadlines.

(*Must Reside In Or Relocate To Colorado*)

Shift

Days (United States of America)

Work Type

Regular

Salary

$21.74 - $30.40 / hr

Benefits

• Outstanding benefits including up to 27 paid days off per year, immediate retirement plan employer contribution up to 9.5%, and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands, travel, and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer+ free student loan coaching and assistance navigating the PSLF program 

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.

Denver Health is an integrated, high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center, a 555-bed acute care medical center, Denver’s 911 emergency medical response system, 10 family health centers, 19 school-based health centers, Rocky Moun