Appeals and Grievance Specialist I

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 and Commercial Large Group plans. 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. 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. 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, Oregon, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, West Virginia, or Wisconsin JOB SUMMARY/PURPOSE Plays a vital role in managing and resolving member and provider appeals and grievances. This position requires exceptional communication skills, keen attention to detail, and a commitment to compliance with regulatory standards. Responsible for investigating, documenting, and facilitating resolutions; and ensuring member and provider satisfaction throughout the process. EXPERIENCE/EDUCATION/QUALIFICATIONS Bachelor’s degree in healthcare, business, or a related field; or equivalent relevant experience required. Experience in computer applications, including Microsoft Office Suite, required. Experience in appeals and grievances strongly preferred. KNOWLEDGE/SKILLS/ABILITIES Familiarity with healthcare laws, regulations, and best practices related to appeals and grievances. Strong problem-solving, organizational, and time-management skills. Attention to detail and commitment to accuracy in documentation and reporting. Excellent verbal and written communication abilities to clearly convey complex information. Ability to manage multiple cases simultaneously and meet deadlines in a fast-paced environment. Ability to manage deadlines while adhering to quality and compliance standards. Commitment to exceptional customer service and stakeholder engagement. Proficiency in case management software and ability to adapt to new technology. PHYSICAL DEMANDS Rarely (1 - 10% of the time) Occasionally (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