Appeals and Grievance Specialist II

# **9165136 Appeals and Grievance Specialist II (Managed Care) – Irving, TX | 12-Week Contract** **Location:** Irving, TX **Job Type:** 12-Week Contract **Company:** Sigma Inc. **Schedule:** Monday–Friday | 8-Hour Shifts ## Join Our Team as an Appeals and Grievance Specialist II! Sigma Inc. is seeking an experienced **Appeals and Grievance Specialist II** to join our healthcare team in **Irving, TX**. This role is ideal for professionals with **Managed Care, Medicare Appeals & Grievances, Claims Review, Medical Terminology, and Healthcare Customer Service** experience. If you have a strong background in **appeals processing, grievance resolution, claims analysis, Medicare regulations, HIPAA compliance, and provider/member communication**, we'd like to hear from you! ## Key Responsibilities - Investigate, review, and resolve member and provider appeals, grievances, and complaints. - Research claim denials, reconsiderations, and redetermination requests. - Interpret member benefits, Medicare policies, CPT/ICD coding, and reimbursement guidelines. - Analyze appeals and grievance data to identify trends and recommend process improvements. - Prepare clear, accurate written correspondence and decision letters to members and providers. - Collaborate with internal departments to ensure timely and compliant case resolution. - Educate members and providers regarding appeal and grievance procedures and benefit coverage. - Maintain HIPAA compliance while handling Protected Health Information (PHI). - Generate reports using Microsoft Word and Excel. - Participate in departmental meetings and continuous quality improvement initiatives. ## Required Qualifications - Minimum **3 years of customer service experience** within a **Managed Care Plan**. - Minimum **2 years of Appeals and Grievance experience** in a Managed Care environment. - Experience researching and resolving healthcare claims, appeals, and grievances. - Knowledge of **Managed Care, Medicare, Claims Processing, Appeals & Grievances**, and healthcare regulations. - Strong analytical, research, and problem-solving abilities. - Excellent written and verbal communication skills. - Good typing and professional letter-writing skills. - Basic computer proficiency, including **Microsoft Word and Excel**. - Ability to work independently while meeting strict deadlines. - Excellent customer service and conflict resolution skills. ## Preferred Qualifications - Knowledge of **CPT and ICD coding**. - Familiarity with **Medicare-covered benefits**, **CMS**, and **TRICARE** regulations. - Experience with **medical terminology**. - Experience analyzing appeals and grievance trends. - Healthcare insurance or health plan experience. ## Required Skills - Appeals & Grievance Processing - Managed Care - Medicare - Claims Review - Claims Resolution - Medical Terminology - CPT Coding - ICD Coding - Healthcare Customer Service - Research & Analysis - HIPAA Compliance - Provider Relations - Member Services - Microsoft Word - Microsoft Excel - Written Communication - Letter Writing - Conflict Resolution - Time Management - Data Analysis