Claims Examiner

Job Description: Claims & Appeals & Grievances (A&G) Specialist – Back Office Operations 

Job Title: Claims & Appeals & Grievances (A&G) Specialist 
Department: Healthcare Operations 
Location: United States (Remote) 
Employment Type: Full-Time 
Experience Required: Minimum 2 years in US Healthcare Back Office Operations 

Pay Range: $17-$20 (based on your experience)

Position Overview 

We are seeking a highly organized and detail-oriented Claims & Appeals & Grievances (A&G) Specialist to join our Healthcare Operations team. The ideal candidate will have a minimum of two years of experience supporting US healthcare back-office operations with expertise in claims processing, appeals, grievances, and administrative support functions. 

This role is responsible for reviewing and processing healthcare claims, researching and resolving claim-related issues, coordinating appeals and grievance activities, ensuring compliance with regulatory requirements, and maintaining accurate documentation. The successful candidate will demonstrate strong analytical skills, attention to detail, and the ability to work efficiently in a fast-paced, quality-driven environment. 

Key Responsibilities 

Claims Operations 

• Review, validate, and process medical, behavioral health, and pharmacy claims in accordance with health plan policies and established business rules. 

• Perform claim research to identify discrepancies, missing information, eligibility concerns, authorization requirements, and benefit coverage issues. 

• Verify member eligibility, provider information, coding accuracy, and supporting documentation prior to claim adjudication or escalation. 

• Analyze suspended, pending, denied, or rejected claims and determine appropriate next steps. 

• Ensure claims are processed accurately within established turnaround times and service level agreements (SLAs). 

• Document all actions, findings, and resolutions within the claims management system. 

Appeals & Grievances 

• Receive, review, and process member and provider appeals and grievances in accordance with CMS, state, federal, and organizational requirements. 

• Research claim history, medical records, benefit plans, provider contracts, and supporting documentation to determine appropriate case resolution. 

• Coordinate with internal clinical, compliance, provider services, customer service, and operations teams to obtain additional information when required. 

• Prepare case summaries, correspondence, and resolution documentation while ensuring completeness and accuracy. 

• Track appeal and grievance cases from receipt through final resolution while meeting regulatory turnaround time requirements. 

• Escalate complex or high-risk cases to appropriate departments as necessary. 

Back Office Operations 

• Perform data entry, record maintenance, document indexing, and quality validation activities. 

• Maintain confidentiality of Protected Health Information (PHI) in accordance with HIPAA regulations. 

• Review operational reports and work queues to prioritize daily workload. 

• Identify processing errors, trends, or recurring issues and recommend corrective actions. 

• Participate in quality audits, process reviews, and continuous improvement initiatives. 

• Support cross-functional operational projects and departmental objectives. 

Compliance & Quality 

• Adhere to CMS, HIPAA, NCQA, and internal compliance standards. 

• Ensure all documentation is complete, accurate, and audit-ready. 

• Meet departmental productivity, quality, accuracy, and turnaround time metrics. 

• Participate in required compliance, privacy, and operational training programs. 

• Maintain current knowledge of healthcare regulations, benefit plans, and organizational policies. 

Required Qualifications 

• High School Diploma or GED required; Associate's or Bachelor's degree preferred. 

• Minimum of 2 years of experience in US Healthcare Back Office Operations. 

• Experience in healthcare claims processing and Appeals & Grievances. 

• Knowledge of commercial, Medicare, and/or Medicaid health plans. 

• Understanding of medical terminology, healthcare benefits, and claim workflows. 

• Familiarity with CPT, ICD-10-CM, HCPCS, and healthcare documentation. 

• Experience working with claims processing systems, workflow management tools, and electronic document management systems. 

• Proficiency with Microsoft Office, including Excel, Word, and Outlook. 

• Strong written and verbal communication skills. 

• Excellent analytical, organizational, and problem-solving abilities. 

Preferred Qualifications 

• Experience in Managed Care, Health Insurance, Third-Party Administration (TPA), or Healthcare Business Process Outsourcing (BPO). 

• Knowledge of healthcare regulations governing appeals and grievance processes. 

• Experience handling high-volume production environments. 

• Familiarity with quality assurance processes and operational audits. 

Core Competencies 

• Claims Processing 

• Appeals & Grievance Administration 

• Claims Investigation 

• Healthcare Documentation Review 

• Data Validation & Quality Assurance 

• Regulatory Compliance 

• HIPAA Compliance 

• Medicare & Medicaid Guidelines 

• Medical Terminology 

• Attention to Detail 

• Critical Thinking 

• Time Management 

• Customer Focus 

• Team Collaboration 

• Problem Solving 

Performance Expectations 

• Achieve established productivity and quality targets. 

• Meet appeal and grievance turnaround time requirements. 

• Maintain high claims processing accuracy. 

• Ensure timely completion of assigned work queues. 

• Demonstrate compliance with HIPAA, CMS, and organizational policies. 

• Contribute to continuous process improvement initiatives. 

• Maintain positive collaboration with internal stakeholders and support teams.