Job Title: Grievances & Appeals Specialist - Claim Appeals
Work Location: In-person, Tampa, FL
Company Overview
CSTS Customer Service and Technology Solutions, LLC is a leading third-party administrator dedicated to transforming the healthcare experience. We specialize in managing the administrative and operational tasks for Medicare Advantage insurance health plans, ensuring compliance with federal regulations while delivering exceptional service to our partners.
If you are passionate about delivering exceptional customer experiences and want to be part of a team that is transforming healthcare, we invite you to apply today!
Position Summary
The Grievances & Appeals (G&A) Specialist (Claim Appeals) is responsible for the accurate and timely intake, investigation, and resolution of claim appeal cases in accordance with federal, state, and CMS regulations, as well as internal policies and procedures. This role ensures that all claim appeal documentation is complete, compliant, and audit-ready while maintaining the highest standards of quality, productivity, and member service. The Specialist collaborates with internal departments, providers, and external stakeholders to ensure claim appeals are resolved fairly and timely in accordance with regulatory and organizational requirements.
Essential Duties and Responsibilities
- Receive, research, and process assigned claim appeal cases from receipt through resolution, ensuring compliance with CMS and state timeliness standards.
- Communicate directly with members, providers, and representatives via phone and written correspondence to collect information, provide case status updates, and ensure clear and professional resolution of inquiries.
- Log, track, and document all case activity in the designated G&A management system, maintaining complete and accurate records to support audit readiness.
- Review member and provider correspondence, evidence, and claim or authorization data to determine case categorization, issue type, and applicable regulations.
- Coordinate the collection of required medical records, claim documentation, or provider input to support case investigation.
- Prepare case summaries, decision letters, and supporting documentation in accordance with CMS correspondence standards and internal templates.
- Facilitate internal and external review processes, including medical director reviews, reconsideration meetings, and delegated entity communications.
- Identify and promptly escalate potential compliance risks, missed timeframes, or complex issues to leadership.
- Maintain up-to-date knowledge of CMS Parts C and D requirements, NCQA standards, and departmental workflows to ensure accurate and compliant case handling.
- Collaborate with internal departments (Customer Service, Claims, UM, Provider Relations, Care Management, etc.) to obtain necessary documentation and ensure complete case resolution.
- Participate in departmental meetings, calibration sessions, and training activities to support continuous quality improvement.
- Assist leadership in identifying process improvement opportunities that enhance efficiency, accuracy, and member satisfaction.
- Handle all member and provider communications with professionalism, empathy, and adherence to HIPAA and company confidentiality standards.
- Support audit requests, data validation efforts, and other special projects as assigned.
Other Duties
This job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilities required of the employee. Other duties may be assigned by G&A leadership as business needs evolve.
Supervisory Responsibility
This job has no supervisory responsibilities.
Required Qualifications
- Microsoft Excel
- Microsoft Outlook
- Medical claim appeals
- Medicare regulations
- Medicare coding guidelines
Required Education and Experience
- High school diploma or GED equivalent.
- Minimum 1-2 years of experience in Medicare healthcare operations.
- Demonstrated experience communicating with members and providers via phone in a professional environment.
- Proficiency with Microsoft Office Suite (Word, Excel, Outlook).
- Strong organizational and written communication skills with attention to compliance detail.
Preferred Education and Experience
- Associate’s degree in Healthcare Administration, Business, or related field.
- Experience working directly in Claim Appeals, Organization/Coverage Determinations, or Medicare Advantage operations.
- Familiarity with CMS systems (HPMS, CTM) and G&A management platforms.
- Knowledge of NCQA standards and Medicaid or DSNP grievance and appeal requirements.
- Prior experience supporting CMS audits, universe creation, or compliance documentation.
Equal Employment Opportunity
We are committed to creating an inclusive workplace where all employees are valued and respected. We are proud to be an Equal Opportunity Employer and do not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, genetic information, veteran status, or any other status protected by applicable law. We encourage candidates from all backgrounds to apply.
Job Type: Full-time
Pay: $22.00 - $27.00 per hour
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Health insurance
- Life insurance
- Paid time off
- Vision insurance
Application Question(s):
- This position is based in the Tampa, FL area and requires working in the office. Are you willing and able to work on-site?
Experience:
- Medicare Medical Claims processing: 1 year (Required)
- Medicare Appeals processing: 1 year (Required)
- Medicare Advantage Health Plan: 1 year (Required)
Work Location: In person
