Grievance and Appeals Specialist

Telligen

. Serve as the primary point of contact for members, providers, and authorized representatives throughout grievance and appeal processes .

Posted 11/3/2026full-timeOak Brook • Illinois • United StatesMid-LevelSenior💰 $62,000 - $75,000 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing grievances and appeals within the healthcare sector, with a strong focus on compliance with Medicaid managed care requirements and effective communication with members and providers. Proficient in analyzing data to identify trends and improve processes while maintaining audit-ready documentation.

Highest-signal resume keywords

Managed Care ExperienceGrievance And Appeal HandlingMedicaid Managed Care KnowledgeFormal Correspondence WritingData Analysis

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Grievance ResolutionAppeal ProcessesClaims ResearchUtilization ManagementCase File PreparationRegulatory ComplianceAudit DocumentationTraining DevelopmentWorkflow DevelopmentData Trend Analysis

Soft Skills

Clear CommunicationProblem SolvingCollaborationSensitivity HandlingTraining Delivery

Tools & Technologies

Microsoft WordMicrosoft ExcelMicrosoft Outlook

Industry Keywords

Healthcare AdministrationMedicaid ProgramsManaged Care ContractsState Fair Hearing ProcessesNCQA Accreditation

About the role

Key responsibilities & impact

Serve as the primary point of contact for members, providers, and authorized representatives throughout grievance and appeal processes
Conduct outbound calls to explain processes, gather facts, request records, and clarify issues
Communicate decisions verbally and in writing using clear, plain language meeting readability and translation requirements
Handle escalated and sensitive contacts, including expedited appeals, executive or regulatory complaints, and Ombudsman inquiries
Represent Telligen at State Fair Hearings, including preparing case summaries and evidence packets
Intake, classify, triage, investigate, and resolve grievances, appeals, and provider disputes
Identify expedited and clinical cases for appropriate routing
Research claims, authorizations, eligibility, benefit coverage, and contract language
Prepare complete case files for clinical review by nurses and medical directors
Effectuate overturned decisions in claims or utilization management systems
Resolve cases within regulatory and contractual timeframes and maintain audit-ready documentation
Collaborate with Utilization Management, Claims, Member Services, Provider Relations, Pharmacy, Quality, and Compliance
Present cases and trends at Grievance & Appeals Committee meetings
Escalate systemic issues, quality-of-care concerns, and suspected fraud, waste, or abuse
Serve as a subject-matter resource
Develop and maintain procedures, workflows, letter templates, and job aids
Translate federal and state contract changes into updated procedures
Analyze grievance and appeal data to identify trends and recommend improvements
Develop and deliver training for new hires and partner departments
Support internal audits, state reviews, and NCQA accreditation readiness

Requirements

What you’ll need

Associate's degree in healthcare administration, business, or a related field, or equivalent work experience
At least 3 years of managed care experience in grievances and appeals, claims, utilization management, or member/provider services, including at least 1 year directly handling grievance or appeal cases
Working knowledge of Medicaid managed care grievance and appeal requirements, including 42 CFR 438 Subpart F, and State Fair Hearing processes
Experience writing formal correspondence to members or providers
Proficiency with Microsoft Word, Excel, and Outlook
Experience with applicable state Medicaid programs and managed care contracts
No employer sponsorship for work authorization now or in the future

Benefits

Comp & perks

100% employee-owned company with employees sharing in company success
Benefits and other compensation available; details provided in Telligen's Benefits Summary
Equal Opportunity Employer
E-Verify participant
Reasonable accommodations during the employment process