A Claims Adjuster or Specialist investigates and evaluates insurance claims. Specializes in a particular type of insurance. Inspects property damage, including damage to homes, buildings and cars; reviews claims after they are submitted; may authorize or deny payment for claims. May work directly for insurers or on behalf of claimants.
Appeals & Grievance Specialist II The CSI Companies - 3.7 Irving, TX Job Details Contract $30 - $34 an hour 9 hours ago Benefits Paid training Disability insurance Health insurance Dental insurance 401(k) Vision insurance Qualifications Healthcare dispute resolution Appeals Customer communication Managed care Managed care organization experience Insurance dispute resolution Regulatory compliance in claims processing Medical coding guidelines Research Medical insurance appeals management Productivity software Insurance claims appeal handling Healthcare coding investigations Healthcare data reporting Full Job Description Appeals & Grievance Specialist Our client is seeking an experienced Appeals & Grievance Specialist to join their team in Irving, TX. This role is responsible for researching, investigating, and resolving member and provider grievances, appeals, and complaint inquiries while ensuring compliance with CMS, TRICARE, state, and federal regulations. The ideal candidate will bring managed care experience, strong analytical skills, and a commitment to delivering exceptional member and provider service.
Hours/Location/Pay/Position Type Schedule:
Monday-Friday 40 hrs/week
Location:
Irving, TX (Onsite)
Pay:
$30.00 - $34.00 per hour
Position Type:
W2 Contract Work Authorization Must be authorized to work in the United States without sponsorship now or in the future. What you'll do Research, investigate, and resolve member and provider grievances, appeals, complaints, claim denials, reconsiderations, and redetermination requests. Interpret health plan benefits, review claims, and apply CPT and ICD coding knowledge to support resolution decisions. Communicate grievance and appeal determinations to members, providers, and authorized representatives in accordance with CMS and TRICARE requirements. Coordinate with internal departments to implement resolution decisions and ensure timely case completion. Review, classify, document, and track complaints and appeals in compliance with state and federal regulatory requirements. Analyze grievance and appeals data to identify trends, root causes, and opportunities for operational improvement. Prepare recurring tracking, trending, and reporting deliverables for leadership review. Recommend process improvements to enhance member satisfaction, provider experience, operational efficiency, and Medicare STAR ratings. Maintain strict adherence to organizational policies, procedures, and regulatory guidelines. Work independently while managing multiple cases and priorities in a fast-paced managed care environment. What we're looking for Minimum 3 years of customer service experience within a Managed Care Plan environment. Minimum 2 years of appeals and grievance experience with Managed Care Plans. Knowledge of health plan benefits, claims review processes, and healthcare regulations. Experience researching and resolving complex member and provider issues. Understanding of CPT and ICD coding principles. Strong analytical, investigative, and problem-solving skills. Ability to interpret policies, regulations, and benefit plans accurately. Excellent written and verbal communication skills. Proficiency with Microsoft Office applications and reporting tools. Ability to work independently and manage workloads effectively. Nice to have Experience supporting Medicare, Medicaid, TRICARE, or other government-sponsored healthcare programs. Previous experience developing appeals, grievance, or quality trend reports. Knowledge of CMS compliance requirements and Medicare STAR measures. Who Should Apply? This opportunity is ideal for healthcare professionals with managed care appeals and grievance experience who enjoy research, investigation, problem-solving, regulatory compliance, and improving member and provider experiences. About Us CSI Companies is a national workforce solutions firm that has been delivering staffing, recruiting, and consulting services across healthcare, technology, financial services, and professional services industries since 1994. We partner with leading organizations to connect talented professionals with meaningful career opportunities. Benefits Offered Weekly pay Medical, dental, and vision insurance Voluntary life and disability coverage 401(k) participation eligibility Paid training opportunities. #VMSLL
