Appeals and Grievances Specialist

 

At Curana Health, we're on a mission to radically improve the health, happiness, and dignity of older adults—and we're looking for passionate people to help us do it.

 

As a national leader in value-based care, we offer senior living communities and skilled nursing facilities a wide range of solutions (including on-site primary care services, Accountable Care Organizations, and Medicare Advantage Special Needs Plans) proven to enhance health outcomes, streamline operations, and create new financial opportunities.

 

Founded in 2021, we've grown quickly—now serving 200,000+ seniors in 1,500+ communities across 32 states. Our team includes more than 1,000 clinicians alongside care coordinators, analysts, operators, and professionals from all backgrounds, all working together to deliver high-quality, proactive solutions for senior living operators and those they care for.

 

Ranked #147 on the Inc. 5000 list of America's fastest-growing private companies, we're just getting started. If you're looking to make a meaningful impact on the senior healthcare landscape, you're in the right place—and we look forward to working with you.

 

For more information about our company, visit CuranaHealth.com

Summary

Make an Impact in Medicare Advantage Member Experience

Are you passionate about helping members navigate complex healthcare issues while ensuring compliance and quality outcomes? Curana Health is seeking an experienced Appeals & Grievances Specialist to join our growing team. In this role, you will investigate and resolve member and provider appeals and grievances, ensuring timely, accurate, and compliant case resolution while helping deliver an exceptional member experience. This position plays a critical role in supporting regulatory compliance, operational excellence, and quality improvement initiatives across the organization.

Essential Duties & Responsibilities

Primary Responsibilities:

• Investigate and resolve member and provider appeals and grievances in a professional, accurate, and timely manner while meeting all contractual and regulatory timeframes.
• Maintain a clear understanding of the differences between medical necessity appeals and claim appeals and apply appropriate processes accordingly.
• Manage appeals and grievance cases from intake through final resolution, including receiving, logging, tracking, monitoring, documenting, requesting supporting documentation, investigating, auditing, resolving, and reporting on cases.
• Respond to member and provider appeals and grievances independently and with minimal supervision.
• Interface with members and providers regarding the status, process, and outcomes of complaints, appeals, and grievances.
• Prepare all appeal and grievance-related correspondence, including acknowledgment letters, determination letters, outcome notifications, and correspondence for escalated levels of review.
• Prepare, attend, and present appeals and grievances documentation for plan hearings, regulatory reviews, audits, and other compliance-related activities as needed.
• Accurately document all appeal and grievance activities, follow-up actions, and final outcomes in designated systems while maintaining comprehensive and secure case files.
• Generate reports, identify trends, and provide recommendations for quality improvement initiatives and operational enhancements.
• Communicate detailed risk management concerns and compliance-related issues to leadership within established timeframes.
• Review appeal and grievance correspondence and proactively obtain additional information from appellants, providers, or other stakeholders as necessary.
• Partner closely with member advocates and internal stakeholders to facilitate effective grievance resolution and an exceptional member experience.
• Assist in coordinating peer review activities involving internal Physician Advisors and external review vendors.
• Collaborate with Utilization Management, Claims, Provider Network, Legal, Compliance, and other business partners to ensure appeal and grievance decisions align with all regulatory, contractual, and organizational requirements.
• Work with leadership and external vendors to resolve complex, high-profile, and escalated appeals and grievance cases.
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Qualifications

Required Qualifications

• High school diploma or GED required.
• Minimum of three (3) years of experience managing Medicare Advantage appeals and grievances.
• Experience working for a Medicare Advantage health plan.
• Experience within Medicare Advantage health insurance, including appeals, grievances, customer service, and complaint resolution.
• Working knowledge of Medicare Advantage regulations, appeals processes, grievance procedures, and complaint resolution requirements.
• Experience investigating and resolving complex member and provider issues in a highly regulated healthcare environment.
• Strong written and verbal communication skills, including the ability to prepare professional correspondence, determination letters, and case documentation.
• Proficiency with Microsoft Office applications, including Word and Excel.
• Strong analytical, organizational, problem-solving, and critical-thinking skills.
• Ability to effectively manage multiple priorities, meet strict deadlines, and maintain a high degree of accuracy and attention to detail.
• Ability to interpret, apply, and adhere to regulatory requirements, policies, and procedures.

Preferred Qualifications

• Experience utilizing appeals and grievances platforms such as QNXT.
• Experience supporting audits, regulatory reviews, compliance activities, or accreditation requirements.