Grievance & Appeals Claims Specialist - Denver Health Medical Plan (*Must Reside In Or Relocate To Colorado*)

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Department

(*Must Reside In Or Relocate To Colorado*)

Job Summary

The Grievance & Appeals Claims Specialist is a key position responsible for handling and resolving client grievances and appeals regarding services and claims. This role ensures that all complaints are addressed promptly and accurately maintaining compliance with regulatory standards and company policies. The specialist is an advocate for clients working to resolve issues and improve overall satisfaction while safeguarding the integrity and efficiency of the organization.

Essential Functions:

• Handle and resolve incoming grievances and appeals in a timely and efficient manner (20%)
• Document all complaints appeals and resolutions accurately in the system. (20%)
• Conduct thorough investigations to gather necessary information for resolving appeals. (10%)
• Communicate effectively with clients providers and internal departments to resolve issues. (10%)
• Ensure compliance with regulatory standards and organizational policies. (10%)
• Collaborate with other departments to address systemic issues and prevent future grievances. (10%)
• Provide regular updates to management on the status of grievances and appeals. (10%)
• Analyze trends in claims grievances and appeals to identify areas for improvement. (10%)

Education:

• High School Diploma or GED required OR
• Associates degree preferred

Work Experience:

• Associates degree and 1 year of claims customer service or grievance and appeals experience required OR
• 3 years of experience in the insurance industry claims experience required OR
• 1 year of QNXT experience required

Licenses:
Knowledge Skills and Abilities:

• Strong knowledge of regulatory requirements and insurance products.
• Excellent communication and interpersonal skills.
• Proven analytical and problem-solving abilities.
• Ability to handle sensitive and confidential information appropriately.
• Proficiency in using relevant software and database systems.
• Strong organizational and time-management skills.
• Understanding of grievance and appeals processes.
• Strong written and verbal communication skills.
• Attention to detail and accuracy.
• Ability to Ability to work independently and as part of a team.
• Ability to manage multiple tasks and meet deadlines.

(*Must Reside In Or Relocate To Colorado*)

Shift

Work Type

Salary

Benefits

• Outstanding benefits including up to 27 paid days off per year immediate retirement plan employer contribution up to 9.5% and generous medical plans

• Free RTD EcoPass (public transportation)

• On-site employee fitness center and wellness classes

• Childcare discount programs & exclusive perks on large brands travel and more

• Tuition reimbursement & assistance

• Education & development opportunities including career pathways and coaching

• Professional clinical advancement program & shared governance

• Public Service Loan Forgiveness (PSLF) eligible employer free student loan coaching and assistance navigating the PSLF program

• National Health Service Corps (NHCS) and Colorado Health Service Corps (CHSC) eligible employer

Our Values

• Respect

• Belonging

• Accountability

• Transparency

All job applicants for safety-sensitive positions must pass a pre-employment drug test once a conditional offer of employment has been made.

Denver Health is an integrated high-quality academic health care system considered a model for the nation that includes a Level I Trauma Center a 555-bed acute care medical center Denvers 911 emergency medical response system 10 family health centers 19 school-based health centers Rocky Mountain Poison & Drug Safety a Public Health Institute an HMO and The Denver Health Foundation.

As Colorados primary and essential safety-net institution Denver Health is a mission-driven organization that has provided billions in uncompensated care for the uninsured. Denver Health is viewed as an Anchor Institution for the community focusing on hiring and purchasing locally as applicable serving as a pillar for community needs and caring for more than 185000 individuals and 67000 children a year.

Located near downtown Denver Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.

Denver Health is an equal opportunity employer (EOE). We value the unique ideas talents and contributions reflective of the needs of our community.

Applicants will be considered until the position is filled.