Appeals and Grievances Specialist

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Curana Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🤝 B2B

⚕️ Healthcare Insurance

B2B • Healthcare Insurance

Curana Health is a healthcare provider focused on senior primary care and on-site clinical services in skilled nursing and senior living communities. The company partners with operators, payors, and Medicare Advantage plans to implement value-based care models, offering physician-led care teams, medical director services, care coordination (including RPM and APCM), behavioral health, and palliative care. Curana emphasizes reducing hospital readmissions, falls, and polypharmacy while improving resident satisfaction through integrated, community-based care supported by technology and payor partnerships.

📋 Description

• 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

• 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

• Health insurance • Retirement plans • Paid time off • Professional development opportunities