Offer summary

Qualifications:

Bachelor’s degree in healthcare, business, or a related field, or equivalent experience required., Two years of experience in appeals and grievances or a related healthcare field is necessary., Experience in data analysis and reporting is required., Proficiency in Microsoft Office Suite and case management software is essential..

Key responsabilities:

Resolve complex member and provider appeals and grievances effectively.

Support junior staff and contribute to process improvements.

Ensure compliance with federal, state, and organizational regulations.

Maintain high attention to detail and manage multiple cases simultaneously.

Job description

Occasionally

This is a remote position in which we are able to employ in the following states: Arizona, Arkansas, Connecticut, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Michigan, Mississippi, Missouri, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin
This position will work pacific timezone hours
JOB SUMMARY/PURPOSE

Responsible for resolving complex member and provider appeals and grievances. This advanced role requires exceptional analytical skills, attention to detail, and the ability to manage challenging situations effectively. Supports junior staff, contributes to process improvements, and ensures strict compliance with federal, state, and organizational regulations.

DEPARTMENT DESCRIPTION

Samaritan Health Plans (SHP) operates a portfolio of health plan products under several different legal structures: InterCommunity Health Plans, Inc. (IHN) is designated as a regional Coordinated Care Organization (CCO) for Medicaid beneficiaries; Samaritan Health Plans, Inc. offers Medicare Advantage, Commercial Large Group, and Commercial Large Group PPO and EPO plans; SHP is also the third-party administrator for Samaritan Health Services’ self-funded employee health benefit plan. As part of an Integrated Delivery System, Samaritan Health Plans is strategically and operationally aligned with Samaritan Health Services’ mission of Building Healthier Communities Together.

EXPERIENCE/EDUCATION/QUALIFICATIONS

Bachelor’s degree in healthcare, business, or a related field; or equivalent relevant experience required. Advanced degree preferred.
Two (2) years experience in appeals and grievances or a related healthcare/health insurance field required.
Experience in data analysis and reporting required.
Experience in computer applications, including Microsoft Office Suite, required.

KNOWLEDGE/SKILLS/ABILITIES

Healthcare Expertise: Deep understanding of healthcare laws, regulations, and best practices related to appeals and grievances.
Analytical & Problem-Solving Skills: Advanced analytical skills to assess cases, identify issues, and determine the best resolution path.
Communication Skills: Strong verbal and written communication skills, capable of conveying complex information effectively. Skilled in conflict resolution and maintaining positive interactions.
Organization & Accuracy: High attention to detail and accuracy in documentation and reporting. Ability to manage multiple cases simultaneously, prioritize tasks, and meet deadlines in a fast-paced environment. Ability to balance competing priorities while ensuring compliance and maintaining quality service.
Customer Service Commitment: Dedication to providing exceptional support and ensuring member and provider satisfaction throughout the process.
Technical Proficiency: Proficient in case management software, Microsoft Office Suite, and other relevant technology.

PHYSICAL DEMANDS

Rarely (1 - 10% of the time)

(11 - 33% of the time)

Frequently

(34 - 66% of the time)

Continually

(67 – 100% of the time)

CLIMB - STAIRS

LIFT (Floor to Waist: 0"-36") 0 - 20 Lbs

LIFT (Knee to chest: 24"-54") 0 – 20 Lbs

LIFT (Waist to Eye: up to 54") 0 - 20 Lbs

CARRY 1-handed, 0 - 20 pounds

BEND FORWARD at waist

KNEEL (on knees)

STAND

WALK – LEVEL SURFACE

ROTATE TRUNK Standing

REACH - Upward

PUSH (0 - 20 pounds force)

PULL (0 - 20 pounds force)

SIT

CARRY 2-handed, 0 - 20 pounds

ROTATE TRUNK Sitting

REACH - Forward

MANUAL DEXTERITY Hands/wrists

FINGER DEXTERITY

PINCH Fingers

GRASP Hand/Fist

PI265248887

Required profile