Grievances & Appeals Specialist
Job Summary
Job Description
Kavaliro is seeking a Grievances & Appeals Specialist for a contract role. This position is crucial for supporting patients and families by investigating complaints, concerns, and feedback. Responsibilities include handling complex cases, mediating disputes, conducting thorough investigations involving patient interviews and medical record reviews, and collaborating with various departments like Legal and Risk Management. The specialist will ensure compliance with company policies and CMS Conditions of Participation, maintaining a patient-centered approach and managing a high caseload with timely documentation to improve quality of care.
Must have:
- Minimum 2 years of experience in grievances, appeals, or patient advocacy
- Strong oral and written communication skills
- Analytical skills for medical record reviews and investigations
- Case management expertise for high volumes
- Conflict resolution and problem-solving abilities
- Technical proficiency in word processing, email, and database management
- Cultural competence and ability to handle sensitive concerns
- Autonomy and resourcefulness in handling complex cases
Good to have:
- Experience in a fast-paced healthcare environment
- Familiarity with patient care software
1 skill required
Job Details
Our client is looking for a Grievances & Appeals Specialist for a contract scenario. The Grievances & Appeals Specialist plays a critical role in supporting patients and families by investigating complaints, concerns, and feedback received by the organization. The responsibilities include:
DUTIES:
REQUIREMENTS:
DUTIES:
- Investigating patient/family complaints related to care quality, physician/provider actions, Company policies, and potential liability.
- Handling highly complex and conflict-heavy cases, requiring innovation and collaboration across departments.
- Working closely with managers, physicians, and staff to resolve patient grievances.
- Coordinating with Legal and Risk Management on medical-legal matters.
- Providing crisis intervention and mediation for complex institutional concerns.
- Conducting case investigations, including interviews with patients/families, medical record reviews, and policy/procedure evaluations.
- Facilitating case conferences and working with leadership to implement corrective action plans for quality improvement.
- Ensuring compliance with CMS Conditions of Participation and Company grievance policies.
- Maintaining a patient and family-centered approach, prioritizing transparency and resolution at the most appropriate levels.
- Managing a high caseload and ensuring timely documentation to meet regulatory timelines.
REQUIREMENTS:
- Minimum 2 years of recent relevant experience in grievances, appeals, or patient advocacy.
- Strong oral and written communication for composing patient responses and synthesizing investigation findings.
- Analytical skills for medical record reviews, quality-of-care investigations, and patient safety concerns.
- Case management expertise, handling high volumes while ensuring timely compliance.
- Conflict resolution and problem-solving in a high-stakes, fast-paced healthcare environment.
- Technical proficiency in word processing, email, database management, and patient care software.
- Cultural competence and ability to navigate sensitive diversity-related concerns.
- Autonomy and resourcefulness in handling complex grievance cases.
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About The Company
We ve been in the staffing business for over 10 years because we receive great satisfaction helping both companies and job candidates find their perfect match. Meet our team Life at Kavaliro We take culture seriously and believe true strength comes from a collaborative and open-minded environment where everyone is supported and empowered to succeed. Learn more Careers at Kavaliro If you want to always have your finger on the pulse of the latest and newest trends in staffing and recruiting, join the Kavaliro team! See internal opportunities Career Advice We offer guidance on resume revisions, clarifying your career objectives, and other advice to help you land your dream job. Visit our blog
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