A Claims Representative accepts and reviews applications for insurance and provides information to insurance agents. Assists insurance customers, answers questions and processes requests to change or cancel policies. May assist with insurance claims that are disputed, review claims and policy coverage and help to negotiate agreements between customers and an insurance company.
GA JR We are seeking a detail-oriented Grievance & Appeals Analyst I with experience in health insurance, managed care, Medicare, or Medicaid. This position is responsible for researching and resolving member grievances and appeals while ensuring cases are handled accurately, timely, and in accordance with regulatory requirements. Responsibilities Review, investigate, and process member grievances and appeals. Research member concerns, claims, benefits, eligibility, and related documentation to determine appropriate resolutions. Communicate with members, providers, and internal departments to gather information and resolve cases. Maintain accurate documentation of case activity, research, findings, and outcomes. Prepare clear written correspondence regarding grievance and appeal determinations. Track cases and ensure all required deadlines are met. Follow applicable CMS, NCQA, Medicare, Medicaid, and health plan guidelines . Escalate complex or sensitive cases when appropriate. Maintain member confidentiality and follow HIPAA requirements. Support departmental quality and compliance standards. Qualifications Previous experience in health insurance, managed care, Medicare, Medicaid, member services, claims, grievances, or appeals . Experience researching and resolving member or customer concerns. Strong written communication and documentation skills. Ability to manage multiple cases and meet strict deadlines. Strong attention to detail and problem-solving skills. Comfortable navigating multiple systems and researching information across different sources. Knowledge of CMS or NCQA requirements is highly preferred. Ideal Background Candidates with experience as a Grievance & Appeals Specialist, Member Services Representative, Claims Processor, Medicare/Medicaid Representative, Healthcare Customer Service Representative, or Managed Care Representative are encouraged to apply.
Pay:
$22-$24 per hour Ascendo is a certified minority owned staffing firm, and we welcome and celebrate diversity. Ascendo is an Equal Opportunity Employer and does not discriminate on the basis of race, color, religion, sex (including pregnancy and gender identity), national origin, political affiliation, sexual orientation, marital status, disability, genetic information, age, parental status, military service or any other characteristic protected by federal, state or local law. CoralGablesAFTEMP
