_{08th September, 2026}

GRIEVANCE & APPEALS QUALITY AUDITOR
 
LOCATION Doral, FL 33178
TYPE On-site
TYPE OF CONTRACT Temp to Perm
PAY RATE $57,000 - $65,000 annually
 
DESCRIPTION:
 
We are seeking a detail-oriented Grievance and Appeals Auditor I to perform comprehensive end-to-end audits of appeals and grievance cases within a managed care healthcare environment. This position is responsible for evaluating case accuracy, procedural compliance, clinical and coverage determinations, and regulatory timeliness while supporting adherence to CMS Medicare Advantage requirements.
 
The ideal candidate brings strong managed care, health insurance, or healthcare operations experience, a solid understanding of Medicare Advantage and CMS regulatory requirements, and the analytical ability to independently identify compliance gaps, document findings, and contribute to ongoing quality and process improvements.
 
Key responsibilities include:

• Conduct pre- and post-resolution audits of member appeals and grievance cases across Medicare Advantage and other managed care lines of business.
• Ensure compliance with CMS Medicare Advantage Appeals and Grievance regulations, internal policies, and required regulatory timeframes.
• Review case files for accuracy and completeness, including member eligibility, benefit coverage, medical necessity determinations, clinical rationale, supporting documentation, benefit interpretation, and plan policy application.
• Review provider and member communications for accuracy and compliance.
• Validate that appropriate clinical and administrative review levels were applied throughout the appeals and grievance lifecycle.
• Assess adherence to CMS requirements for notices, including denial letters, appeal determinations, and grievance responses.
• Identify procedural errors, compliance gaps, and documentation deficiencies.
• Evaluate the timeliness of case resolution against applicable regulatory standards.
• Document audit findings with clear rationale, regulatory citations, and impact assessments.
• Support audit readiness and regulatory examination activities.
• Prepare detailed audit reports outlining case review findings, decision accuracy, procedural and compliance deviations, and potential financial, operational, or regulatory risk exposure.
• Track audit outcomes to identify trends in appeals and grievance processing errors.
• Support reporting for compliance committees, regulatory audits, and internal quality initiatives.
• Provide feedback to Grievance and Appeals teams regarding identified errors and improvement opportunities.
• Recommend corrective actions, training needs, and process enhancements.
• Identify systemic issues and collaborate with leadership, compliance, and operational teams to implement solutions.
• Escalate potential compliance risks or regulatory violations as appropriate.
• Partner with clinical reviewers, compliance officers, and operational leaders to resolve complex case issues.
• Communicate audit findings clearly to both technical and non-technical stakeholders.
• Serve as a subject matter resource on CMS appeals and grievance requirements and managed care compliance standards.

REQUIREMENTS:

• High School Diploma or GED required.
• Minimum of 5 years of experience in managed care, health insurance, or healthcare claims/appeals operations.
• At least 1 year of experience in audit, compliance review, or quality assurance related to appeals and grievances.
• Strong understanding of Medicare Advantage operations and CMS regulatory requirements.
• Experience directly working with Medicare Advantage appeals and grievance processes preferred.
• Familiarity with clinical review processes and coverage determination standards preferred.
• Knowledge of healthcare regulatory compliance frameworks and audit methodologies preferred.
• Experience interpreting CMS regulatory guidance and applying it operationally preferred.
• Strong analytical and critical-thinking skills.
• High attention to detail and accuracy.
• Ability to interpret complex regulatory requirements.
• Strong documentation and written communication skills.
• Ability to work independently in a regulated, production-driven environment.
• Proven ability to identify trends and drive process improvements.
• Strong organizational and time-management skills.
• An equivalent combination of education and experience may be considered.

At ttg, "We believe in making a difference One Person at a Time," ttg OPT.

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