Grievance and Appeals Specialist

About the role

As the Grievance and Appeals Specialist, you will be responsible for independently resolving member and provider grievances and appeals within applicable state Medicaid, federal, contractual, and accreditation timeframes. You will work directly with members, providers, and authorized representatives and collaborate with Utilization Management, Claims, Member Services, Provider Relations, Pharmacy, Quality, and Compliance to achieve fair, accurate, and well-documented outcomes. You will manage moderately complex cases, support process improvement, and develop procedures and training materials.

The Illinois Tailored Care Management Program helps individuals with complex health and social needs transition from nursing facilities and Specialized Mental Health Rehabilitation Facilities (SMHRFs) to community-based living. Through person-centered care management and coordinated support services, the program empowers members to live more independently and thrive in their communities.

What You'll Do

• Serves as the primary point of contact for members, providers, and authorized representatives throughout the grievance or appeal process
• Conducts outbound calls to explain the process, gather facts, request records, and clarify the issue under review
• Communicates decisions verbally and in writing using clear, plain language that meets applicable readability and translation requirements
• Handles escalated and sensitive contacts, including expedited appeals, executive or regulatory complaints, and Ombudsman inquiries, with professionalism and empathy
• Represents Telligen at State Fair Hearings as assigned, including preparation of case summaries and evidence packets
• Intakes, classifies, triages, investigates, and resolves grievances, appeals, and provider disputes
• Identifies expedited and clinical cases for appropriate routing
• Researches claims, authorizations, eligibility, benefit coverage, and contract language
• Prepares complete case files for clinical review by nurses and medical directors
• Effectuates overturned decisions in claims or utilization management systems
• Resolves cases within applicable regulatory and contractual timeframes and maintains accurate, complete, audit-ready documentation in the grievance and appeals system
• Collaborates with Utilization Management, Claims, Member Services, Provider Relations, Pharmacy, Quality, and Compliance to investigate issues and address root causes
• Presents cases and trends at Grievance & Appeals Committee meetings
• Escalates systemic issues, potential quality-of-care concerns, and suspected fraud, waste, or abuse to the appropriate team
• Serves as a subject-matter resource
• Develops, documents, and maintains desk-level procedures, workflows, letter templates, and job aids
• Translates federal and state contract changes into updated procedures in partnership with Compliance
• Analyzes grievance and appeal data to identify trends, bottlenecks, and repeat issues and recommend improvements
• Develops and delivers training for new hires and partner departments
• Supports internal audits, state reviews, and NCQA accreditation readiness, including preparation of case universes and corrective action plans

Required Skills and Experience

• Associate's degree in healthcare administration, business, or a related field, or equivalent work experience
• At least 3 years of managed care experience in grievances and appeals, claims, utilization management, or member/provider services, including at least 1 year directly handling grievance or appeal cases
• Working knowledge of Medicaid managed care grievance and appeal requirements, including 42 CFR 438 Subpart F, and State Fair Hearing processes
• Experience writing formal correspondence to members or providers
• Proficiency with Microsoft Word, Excel, and Outlook
• Experience with applicable state Medicaid programs and managed care contracts

Preferred Skills and Experience

• Experience writing procedures, building workflows, or leading a process improvement project
• Familiarity with Medicare Part C appeals, NCQA standards, medical terminology, CPT, or ICD-10 coding
• Experience training or mentoring peers

Benefits

• A general description of the benefits and other compensation available for this position can be found in Telligen's Benefits Summary.
• We’re on a mission to transform lives and economies by improving health.
• Ownership: As a 100% employee-owned company, our employee-owners drive our business and share in our success.
• Community: We show up - for our clients, our communities and each other. Being a responsible corporate partner is part of who we are.
• Ingenuity: We value bold ideas and calculated risks. Innovation thrives when we challenge the status quo and listen to diverse perspectives.
• Integrity: We foster a respectful, inclusive, and collaborative environment built on trust and excellence.
• Thank you for your interest in Telligen!
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• While we use artificial intelligence tools to enhance our initial screening process, all applications are thoroughly reviewed by our human recruitment team to ensure a fair and comprehensive evaluation of each candidate.

• Telligen will not provide sponsorship for this position.
• If you will require sponsorship for work authorization now or in the future, we cannot consider your application at this time.
• We will not accept 3rd party solicitations from outside staffing firms.