Grievances & Appeals Senior Specialist

Regular
Exempt

GENERAL DESCRIPTION:
Analyzes, investigates, resolves, and answers grievances received through the Center for Medicaid and Medicare Services (CMS) and Complaint Tracking Module (CTM), pre-service appeals, Office of Insurance Commissioner (OIC), and Administrative Organization Determinations (AOD). Ensure timely resolution of cases following contractual obligations and regulatory requirements applicable across all lines of business (LOB) in the company.
ESSENTIAL FUNCTIONS:
•Records, manages, and resolves cases submitted through the CTM. Complies with verbal contact with the insured and/or authorized representative, or provider during the CTM case investigation process to document and categorize the issue presented, and review the documentation provided by operational areas to ensure proper resolution of cases.
•Document in English the chronology of investigation and resolution on the CMS database, applying the contractual language of benefits and covered services according to the evidence of coverage, or others.




•Evaluate in the investigation whether a root cause can be identified for the issue. If a root cause is determined, collaborate with the management of the affected operational areas to develop and implement corrective action plans aimed at minimizing the recurrence of CTMs or grievances.
•Actively participate in the CTM workgroup, engaging with leaders from other Departments or Units to review RCA and coordinate on sustainable action plans to prevent future occurrences.
•Complies with the validation and registration on electronic platforms, as applicable for the pre-service appeals processes, such as Clinical, USA, Dental, SSBCI, and Part B medication.
•If a reconsideration or member request for a pre-service appeal is denied by the Classicare LOB, it is responsible for submitting the cases to the CMS contracted Independent Review Entities (IRE - Maximus). If the reconsideration or member request is den

📌 Grievances & Appeals Senior Specialist (San Juan)
🏢 MCS Healthcare Holdings, LLC (MCS)
📍 San Juan