Kavaliro
Grievances & Appeals Specialist
Our client is looking for a Grievances & Appeals Specialist for a contract scenario. The Grievances & Appeals Specialist plays a critical role in supporting patients and families by investigating complaints, concerns, and feedback received by the organization. The responsibilities include: Investigating patient/family complaints related to care quality, physician/provider actions, company policies, and potential liability. Handling highly complex and conflict-heavy cases, requiring innovation and collaboration across departments. Working closely with managers, physicians, and staff to resolve patient grievances. Coordinating with Legal and Risk Management on medical-legal matters. Providing crisis intervention and mediation for complex institutional concerns. Conducting case investigations, including interviews with patients/families, medical record reviews, and policy/procedure evaluations. Facilitating case conferences and working with leadership to implement corrective action plans for quality improvement. Ensuring compliance with CMS Conditions of Participation and company grievance policies. Maintaining a patient and family-centered approach, prioritizing transparency and resolution at the most appropriate levels. Managing a high caseload and ensuring timely documentation to meet regulatory timelines. Requirements: Minimum 2 years of recent relevant experience in grievances, appeals, or patient advocacy. Strong oral and written communication for composing patient responses and synthesizing investigation findings. Analytical skills for medical record reviews, quality-of-care investigations, and patient safety concerns. Case management expertise, handling high volumes while ensuring timely compliance. Conflict resolution and problem-solving in a high-stakes, fast-paced healthcare environment. Technical proficiency in word processing, email, database management, and patient care software. Cultural competence and ability to navigate sensitive diversity-related concerns. Autonomy and resourcefulness in handling complex grievance cases. Kavaliro provides Equal Employment Opportunities to all employees and applicants. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. Kavaliro is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Kavaliro will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please respond to this posting to connect with a company representative.
Our client is looking for a Grievances & Appeals Specialist for a contract scenario. The Grievances & Appeals Specialist plays a critical role in supporting patients and families by investigating complaints, concerns, and feedback received by the organization. The responsibilities include: Investigating patient/family complaints related to care quality, physician/provider actions, company policies, and potential liability. Handling highly complex and conflict-heavy cases, requiring innovation and collaboration across departments. Working closely with managers, physicians, and staff to resolve patient grievances. Coordinating with Legal and Risk Management on medical-legal matters. Providing crisis intervention and mediation for complex institutional concerns. Conducting case investigations, including interviews with patients/families, medical record reviews, and policy/procedure evaluations. Facilitating case conferences and working with leadership to implement corrective action plans for quality improvement. Ensuring compliance with CMS Conditions of Participation and company grievance policies. Maintaining a patient and family-centered approach, prioritizing transparency and resolution at the most appropriate levels. Managing a high caseload and ensuring timely documentation to meet regulatory timelines. Requirements: Minimum 2 years of recent relevant experience in grievances, appeals, or patient advocacy. Strong oral and written communication for composing patient responses and synthesizing investigation findings. Analytical skills for medical record reviews, quality-of-care investigations, and patient safety concerns. Case management expertise, handling high volumes while ensuring timely compliance. Conflict resolution and problem-solving in a high-stakes, fast-paced healthcare environment. Technical proficiency in word processing, email, database management, and patient care software. Cultural competence and ability to navigate sensitive diversity-related concerns. Autonomy and resourcefulness in handling complex grievance cases. Kavaliro provides Equal Employment Opportunities to all employees and applicants. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws. Kavaliro is committed to the full inclusion of all qualified individuals. In keeping with our commitment, Kavaliro will take the steps to assure that people with disabilities are provided reasonable accommodations. Accordingly, if reasonable accommodation is required to fully participate in the job application or interview process, to perform the essential functions of the position, and/or to receive all other benefits and privileges of employment, please respond to this posting to connect with a company representative.