Grievance and Appeals Specialist

Job Locations US-RI-Smithfield
Req No.
Grievance And Appeals
Regular Full-Time
Prof. Services & Support


This position is responsible for  receiving, researching and facilitating resolution of member/provider grievances, appeals and complaints. Determines applicable compliance criteria based on Medicaid, Medicare and Commercial regulations and ensures workflow is managed to compliance turn around times. Interprets and explains the company’s benefits, policies and procedures to members and providers as they relate to grievances, appeals and complaints. Tracks and monitors movement of assigned cases through functional units and systems while ensuring that resolution meets established timelines.

Communicates with members/providers either verbally or in writing as required and within established timelines to acknowledge and resolve grievances, appeals and complaints. Administers ongoing grievances, appeals and complaint tracking, trending and reporting for regulatory agencies and maintains secure and efficient processes for regulatory record keeping of related documents and the correspondence and reporting needs that support these requirements, with the ability to produce all required documents for audits and regulatory review. Evaluates all grievances, appeals and complaints for trend purposes, and reports findings to management. Establishes and maintains cohesive and successful interdepartmental relationships within the organization.


This position will support all lines of business for the organization.


  • Responsible for accurate identification of all Medicaid, Medicare and Commercial grievance and complaints.
  • Review and evaluate all grievances, appeals and complaints submitted to the company while adhering to established timelines and initiate electronic tracking and distribution to the appropriate department for resolution
  • Participates in Rhody Health Options Quality committee representing Grievance and Appeals
  • Interprets and explains the company’s benefits, policies and procedures to members and providers as they relate to grievances, appeals and complaints. Communicate with members/providers as necessary to provide updates or obtain additional information needed for decision making
  • Generate initial member acknowledgment (verbal and/or written)
  • Initiate electronic tracking of all grievances, appeals and complaints including scanning of documents as needed and attaching to the member record
  • Monitor progress of each grievance, appeal and complaint by using reports and tracking techniques to ensure decisions are rendered within the required time frames
  • Follow-up with responsible departments and delegated entities to ensure compliance
  • Document final resolutions along with all required data to facilitate accurate reporting
  • Ensures final resolution letters are generated within the required timelines
  • Quality checks member and provider facing letters and when appropriate obtains legal opinion on language
  • Builds effective and successful interdepartmental relationships with all areas of the company and utilizes good communication and customer service skills in responding to internal and external inquiries about the grievance, appeal and complaint process while being able to respond quickly regarding the status.
  • Generate required reports on a pre-determined or ad hoc basis, including but not limited to OHIC and EOHHS requirements and other reports as needed for analysis and trending.
  • Produces reports for NCQA and  EOHHS audits, and participates in the compiling of all grievance, appeal and complaint records selected for on-site audits.
  • Other duties as assigned
  • Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and  the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents



  • Associates Degree
  • A minimum of Five (5) years’ experience in a Managed Care or health care environment
  • A minimum of Two (2) years’ experience with Medicare benefits and compliance
  • Strong prioritization and time management skills
  • Excellent customer service orientation and phone etiquette
  • Strong Interpersonal Skills
  • Knowledge of medical terminology
  • Business writing experience (relative to producing letters and other written forms of communication per industry standards)
  • Working knowledge of claims adjudication and coding
  • Intermediate to Advanced skills in Microsoft Office (Word, Excel, Outlook)
  • Demonstrated ability to effectively prioritize and execute tasks in a high-pressure environment and meet contractual timelines
  • Demonstrated ability to excel in a team environment as well as independently
  • Demonstrated ability of creative and effective problem resolution


  • Bachelor Degree
  • Experience in communicating with provider networks
  • Certified Professional Coder (CPC) preferred or working knowledge of ICD-9 codes, HCPC and CPT procedure codes

Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.

Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at

Neighborhood is an EOE M/F/D/V and an E-Verify Employer


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