Jobs in the United States

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Added 2 mins ago
Associate Director, Global Medical Review
Otsuka America Pharmaceutical Inc.
Jefferson City, MO
The Associate Director, Global Medical Review provides input into the medical review of safety data for investigational and marketed products. The role is responsible for ensuring…
Added 3 mins ago
Coordinator BPS Cust Serv
Acosta Group
Chesterfield, MO
+ Investigate rules engine issues and follow established resolution procedures
Added 3 mins ago
Coordinator BPS Cust Serv
Acosta Group
Chesterfield, MO
+ Investigate rules engine issues and follow established resolution procedures
Added 3 mins ago
Coordinator BPS Cust Serv
Acosta Group
Chesterfield, MO
+ Investigate rules engine issues and follow established resolution procedures
Added 6 mins ago
Properties Project Manager
UMB Bank
Kansas City, MO
+ Communicate, facilitate, and manage resolution to complex issues and challenging situations and personnel.
Added 6 mins ago
Integration & Business Acceleration Associate
Indeed
Saint Louis, MO
The Integration & Business Acceleration Associate is a key member of Indeed's Corporate Development team. They help provide the foundation for successful integrations and integration…
Added 7 mins ago
Associate Banker I - Wildwood (30 hour)
TD Bank
Wildwood, NJ
Demonstrated effective problem-solving skills
Added 8 mins ago
Assistant Director, Finance & Administration
Trustees of Princeton University
Princeton, NJ
Added 9 mins ago
Help Desk Specialist
Texas Farm Bureau and Affiliated Companies
Waco, TX
Provide after-hours problem resolution as required.
Added 9 mins ago
Residential Loan Processor I
Forcht Bank
Lexington, KY
…follow-up within established procedures and authority, document the resolution, and escalate material or non-routine matters with a clear summary of the…
Added 9 mins ago
WORKPLACE AMBASSADOR AREA MANAGER
Compass Group, North America
Saint Louis, MO
+ Monitor events and in-office activities to support employee and guest satisfaction and timely problem resolution.
Added 10 mins ago
L
IT Field Support Technician I
Labcorp
Remote, United States
- $25 to $32 USD / hour
Provide technical support, troubleshooting, and issue resolution for hardware, software, network connectivity, and business applications.
Added 12 mins ago
Healthcare Accounts Receivable Team Lead
Alteva RCM
Queens, NY
…strengthen financial performance by supporting timely and accurate resolution of accounts. This position is ideal for a hands-on revenue cycle professional who is passionate about…
Added 12 mins ago
EB
Assistant Director of Nursing RN
Ecumen Branding
Duluth, MN
- $90,000 to $105,000 USD / year
…corrective action to team members, addressing complaints and problem…
Added 13 mins ago
Biomedical Technician / Equipment Support Specialist - Information Systems
Blue Water Thinking
Phoenix, AZ
…candidate should possess a strong technical background, excellent problem-solving skills, and a commitment to maintaining high standards of patient care through the proper functioning of…
Added 13 mins ago
RD
Sr eBilling Analyst
RR Donnelley
Remote, United States
- $25 to $36.97 USD / hour
…process administration, research and analysis, troubleshooting, problem resolution, reporting and any special assignments. The position is also responsible for creating budget projections…
Added 16 mins ago
Non-Destructive Assay Manager - Materials Science Division
LLNL
Livermore, CA
…within a high-hazard nuclear facility. You will report to the Associate Superblock Director for Integration and Planning and support them in developing efficient Superblock processes and…
Added 18 mins ago
SB
Assistant Director - Washington DC Internship Program
SUNY Brockport NY
Washington, DC
- $60,245 to $66,269 USD / year
Serves as primary program administrator when Associate Director is traveling or away.
Added 18 mins ago
Technical Support Specialist Tier I
Schneider Downs
Pittsburgh, PA
…including exceptional customer service, advanced troubleshooting, problem determination and problem resolution to all network users at Schneider Downs. This role troubleshoots issues to…
Added 19 mins ago
FC
Circulation Services Supervisor I
Frederick County Government
Frederick, MD
- $65,105.85 to $110,679.95 USD / year
…independent judgment in staff scheduling and customer service resolution, and recommends - rather than establishes - policy or procedural changes, with decisions typically reviewed by…
Added 22 mins ago
AD, Pre-Construction
Chewy, Inc.
Bellevue, WA · Boston, MA · Plantation, FL
Chewy is seeking an experienced Associate Director of Construction to lead a team responsible for delivering capital projects across our Fulfillment Centers, Pharmacies, and Corporate Hubs.…
Added 22 mins ago
MH
RN Clinical Nurse II Ambulatory Infusion
MedStar Health
Baltimore, MD
- $35 to $56.91 USD / hour
Effectively uses problem identification and resolution skills focusing on the clinical scenario to resolve the apparent concern. Follows the chain of command by consulting with other…
Added 22 mins ago
MH
RN Clinical Nurse II Ambulatory Infusion Oncology
MedStar Health
Baltimore, MD
- $35 to $56.91 USD / hour
Effectively uses problem identification and resolution skills focusing on the clinical scenario to resolve the apparent concern. Follows the chain of command by consulting with other…
Added 22 mins ago
MH
RN Clin Nurse Unit Based Per Diem
MedStar Health
Baltimore, MD
- $36.5 to $60.34 USD / hour
Effectively uses problem identification and resolution skills focusing on the clinical scenario to resolve the apparent concern. Follows the chain of command by consulting with other…
Added 22 mins ago
MH
RN Clin Nurse Unit Based Per Diem
MedStar Health
Baltimore, MD
- $36.5 to $60.34 USD / hour
Effectively uses problem identification and resolution skills focusing on the clinical scenario to resolve the apparent concern. Follows the chain of command by consulting with other…

Amerihealth Caritas

Appeals & Grievance Case Resolution Specialist

United States

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Job details

Education: High school diploma
Posting language: English
Posted: Nov 5, 2026

Original job description

For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement. Your career starts now. We’re looking for the next generation of health care leaders. At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you. Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com. Job Summary The Appeals & Grievance Case Resolution Specialist is responsible for the full life cycle of assigned member and/or provider appeals and grievance cases. Working under general supervision, this role conducts case intake, investigation, and documentation to ensure accurate and timely resolution consistent with federal state, and accreditation standards. The Specialist serves as a key liaison between members, providers, and internal departments to resolve issues effectively, ensuring the integrity of the appeals and grievance process and compliance with CMS, NCQA, URAC, and state regulatory requirements. Essential Functions Case Management

Research and analyze case documentation, including benefit coverage, prior authorizations, claims, and regulatory guidance.
Communicate with members, providers, or representative to clarify appeal intent and gather missing documentation including incoming calls, outgoing calls, and phone queue work as assigned.
Prepare complete and compliant case files, ensuring all required documentation is included.
Track case progress and maintain compliance with turnaround times and documentation standards.
Generate accurate and timely determination and acknowledgement letters.

Investigation and Resolution

Collaborate with internal departments such as Claims, Medical Management, Legal, and Compliance to obtain necessary information for resolution.
Identify potential compliance issues or risk factors requiring escalation.
Participate in case discussions, internal committee reviews, or external fair hearing preparation as assigned.
Document all activities, correspondence, and outcomes in the case management system with attention to detail and accuracy.

Compliance & Quality

Ensure case handling meets all application federal and state regulatory requirements, including with CMS, NCQA, and URAC.
Maintain confidentiality and protect member information in compliance with HIPPA regulations.
Identify opportunities for process improvements to enhance quality and efficiency.

Team Collaboration

Serve as a resource to peers and administrators for routine case-related questions.
Maintain professional communication with members, providers, and internal stakeholders.
Participate in team meetings and contribute to continuous improvement initiatives.

Education/Experience

Associate’s Degree: in Health Administration, Business, or related field preferred
High School Diploma/GES Required

Preferred Experience Level:

Knowledge of medical terminology, benefit interpretation, and regulatory processes preferred. Prior experience working with CMS, Medicaid, or state-regulated appeals processes preferred.
2 to 3 years experience in healthcare operations, managed care, or grievance/appeals coordination.

Other Skills

Proficiency in Microsoft Office Suite (Word, Excel, Outlook, etc.).
Strong attention to detail and organization.
Excellent written and verbal communication.
Ability to manage multiple priorities in a fast-paced environment.
Strong analytical and problem-solving abilities.
Customer service orientation with professional communication etiquette.

Our Comprehensive Benefits Package Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

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