Job Description

PrimeWest Health

is seeking a detail-oriented professional to manage member

Appeals and Grievances (A&G)

in compliance with State and Federal regulations and organizational policy. This position ensures timely and accurate administration of A&G processes, including State Appeals (Fair Hearings), administrative law judge hearings, and district court hearings.

Key Responsibilities:

Administer A&G processes per DHS and CMS standards. Maintain accurate documentation and confidentiality of all case records. Support audits related to Part C and Part D, and assist Quality & Utilization Management as needed. Coordinate interdepartmental communication and reporting. Collaborate with the Chief Senior Medical Director and leadership team to ensure compliance and quality outcomes.

What You'll Do

Own the process

: Intake and manage Appeals & Grievances cases from start to finish.

Investigate thoroughly

: Research case details through internal systems, provider calls, and medical record collection.

Stay compliant

: Ensure all regulatory timelines are met and documentation is accurate.

Collaborate with clinicians

: Coordinate case reviews and deliver timely, member-focused resolution letters.

Support leadership

: Assist with reports, applications, mailings, and quality initiatives.

Analyze & report

: Handle data entry, create charts, and prepare quarterly reports for State and CMS requirements.

Be the detail expert

: Document every step of each case per strict regulatory standards.

Engage in hearings

: Attend State Appeals, Fair Hearings, and court hearings as needed.

Stay responsive

: Participate in on-call rotation for expedited requests and ensure mail duties are covered.

Drive quality

: Work closely with Quality Specialists on Quality of Care issues and assist with audits.

Stay informed

: Keep up with legislation and compliance changes to ensure accurate processes.

Enhance member experience

: Respond professionally and promptly to complaints about benefits, eligibility, claims, and pharmacy issues.

Collaborate & contribute

: Join the Grievance Review Workgroup and support quality assurance activities.
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What Makes You a Great Fit

You're detail-driven and thrive in a regulated environment. You have strong communication skills and can navigate complex processes with confidence. Experience in healthcare compliance, appeals, grievances, or quality management? That's a big plus!

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Why You'll Love Working Here

At PrimeWest Health, we don't just offer jobs--we offer careers with purpose. You'll enjoy:

Medical Insurance

Vision Materials Coverage

Long-Term Disability (LTD) Coverage

Life Insurance

Pension Plan (PERA)

13 Paid Holidays

Vacation Bank

Sick Leave Bank

Fitness Room Onsite

Plus, you'll join a team that values collaboration, innovation, and making a real difference in the lives of our members.

Apply today and start making a difference!