Appeals and Grievance specialist

Clear Expectations and Deliverables * Review and investigate member and provider appeals and grievances. * Analyze medical records, claims, and supporting documentation. * Prepare clear, accurate, and compliant resolution letters. * Meet regulatory and turnaround time requirements. * Maintain thorough documentation in Epic, Innovare, and other case management systems. * Collaborate with clinical and operational teams to resolve issues effectively. Skills Required * Appeals and grievances management * Epic and Innovare proficiency * Medical record review and analysis * Regulatory compliance knowledge * Strong written and verbal communication * Attention to detail and accuracy * Time management and organization * Problem-solving and critical thinking * Microsoft Office Suite ** Must live and be based in Southern California, LA county preferably **