Appeals & Grievance Management
• Review and process appeals and grievances related to denied services, claims, or authorizations.
• Ensure all cases are handled in accordance with established policies, procedures, and regulatory requirements.
• Track and manage appeals to ensure adherence to strict timelines and service level agreements.
Documentation & Case Preparation
• Gather and organize required documentation, including medical records, claim information, and supporting evidence.
• Maintain accurate, complete, and well-documented case files for all appeals and grievances.
• Prepare case summaries and materials for internal or external review.
Coordination & Collaboration
• Coordinate with internal teams such as claims, clinical reviewers, compliance, and legal to facilitate case reviews.
• Serve as a liaison between members, providers, and internal stakeholders throughout the appeals process.
• Escalate complex or high-risk cases as appropriate.
Communication & Stakeholder Support
• Communicate clearly and professionally with members, patients, or providers regarding appeal status, requirements, and outcomes.
• Respond to inquiries and provide guidance on the appeals and grievance process.
• Deliver difficult or sensitive information with professionalism and empathy.
Compliance & Quality Assurance
• Ensure compliance with applicable federal, state, and organizational regulations and guidelines.
• Monitor and support adherence to internal quality standards and audit requirements.
• Identify process gaps or inefficiencies and recommend improvements.
• High school diploma or equivalent required; associate’s or bachelor’s degree preferred.
• 2+ years of experience in healthcare, insurance, customer service, or a related field.
• Strong attention to detail and accuracy in documentation and data handling.
• Excellent organizational and time management skills, with the ability to manage multiple cases simultaneously.
• Clear and professional written and verbal communication skills.
• Ability to interpret and apply policies, procedures, and regulatory guidelines.
• Strong problem-solving skills and ability to handle sensitive or escalated situations.
• Proficiency in Microsoft Office Suite and case management systems.
SGC is a Certified Small Diverse Business for the Commonwealth of PA serving Harrisburg, Hershey, Mechanicsburg, Carlisle, Lancaster, Allentown, State College, York, Sunbury, Philadelphia & Baltimore.
