Appeals and Grievances Specialist

Curana Health

Appeals & Grievances Specialist resolving complex healthcare appeals for Medicare Advantage members. Ensuring compliance, quality outcomes, and exceptional member experience at Curana Health.

Posted 7/21/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSeniorWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing Medicare Advantage appeals and grievances, ensuring compliance with regulatory requirements while delivering exceptional member experiences. Proficient in documentation, communication, and collaboration with various stakeholders to resolve complex issues effectively.

Highest-signal resume keywords

Medicare Advantage Appeals ManagementRegulatory Compliance KnowledgeStrong Written and Verbal CommunicationAnalytical and Problem-Solving SkillsMicrosoft Office Proficiency

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Appeals Process ManagementGrievance ResolutionDocumentation and ReportingCase InvestigationQuality Improvement Initiatives

Soft Skills

Organizational SkillsAttention to DetailCritical ThinkingTime Management

Tools & Technologies

Microsoft WordMicrosoft Excel

Industry Keywords

Medicare AdvantageHealthcare ComplianceCustomer ServiceComplaint ResolutionRegulatory Requirements

About the role

Key responsibilities & impact

Investigate and resolve member and provider appeals and grievances in a professional, accurate, and timely manner while meeting all contractual and regulatory timeframes.
Maintain a clear understanding of the differences between medical necessity appeals and claim appeals and apply appropriate processes accordingly.
Manage appeals and grievance cases from intake through final resolution, including receiving, logging, tracking, monitoring, documenting, requesting supporting documentation, investigating, auditing, resolving, and reporting on cases.
Respond to member and provider appeals and grievances independently and with minimal supervision.
Interface with members and providers regarding the status, process, and outcomes of complaints, appeals, and grievances.
Prepare all appeal and grievance-related correspondence, including acknowledgment letters, determination letters, outcome notifications, and correspondence for escalated levels of review.
Prepare, attend, and present appeals and grievances documentation for plan hearings, regulatory reviews, audits, and other compliance-related activities as needed.
Accurately document all appeal and grievance activities, follow-up actions, and final outcomes in designated systems while maintaining comprehensive and secure case files.
Generate reports, identify trends, and provide recommendations for quality improvement initiatives and operational enhancements.
Communicate detailed risk management concerns and compliance-related issues to leadership within established timeframes.
Review appeal and grievance correspondence and proactively obtain additional information from appellants, providers, or other stakeholders as necessary.
Partner closely with member advocates and internal stakeholders to facilitate effective grievance resolution and an exceptional member experience.
Assist in coordinating peer review activities involving internal Physician Advisors and external review vendors.
Collaborate with Utilization Management, Claims, Provider Network, Legal, Compliance, and other business partners to ensure appeal and grievance decisions align with all regulatory, contractual, and organizational requirements.
Work with leadership and external vendors to resolve complex, high-profile, and escalated appeals and grievance cases.

Requirements

What you’ll need

High school diploma or GED required.
Minimum of three (3) years of experience managing Medicare Advantage appeals and grievances.
Experience working for a Medicare Advantage health plan.
Experience within Medicare Advantage health insurance, including appeals, grievances, customer service, and complaint resolution.
Working knowledge of Medicare Advantage regulations, appeals processes, grievance procedures, and complaint resolution requirements.
Experience investigating and resolving complex member and provider issues in a highly regulated healthcare environment.
Strong written and verbal communication skills, including the ability to prepare professional correspondence, determination letters, and case documentation.
Proficiency with Microsoft Office applications, including Word and Excel.
Strong analytical, organizational, problem-solving, and critical-thinking skills.
Ability to effectively manage multiple priorities, meet strict deadlines, and maintain a high degree of accuracy and attention to detail.
Ability to interpret, apply, and adhere to regulatory requirements, policies, and procedures.

Benefits

Comp & perks

Health insurance
Retirement plans
Paid time off
Professional development opportunities