_{08th September, 2026}

GRIEVANCE AND APPEALS ANALYST
 
LOCATION: Doral, FL 33178
TYPE: On-site
TYPE OF CONTRACT: Temp to Perm
PAY RATE: $22.00 - $24.00 per hour
 
DESCRIPTION:
 
We are seeking a detail-oriented Grievance and Appeals Analyst to review, investigate, and resolve member grievances, appeals, and complaints within a managed care healthcare environment. This position is responsible for ensuring cases are handled accurately, timely, and in accordance with applicable CMS, NCQA, and state regulatory requirements.
 
The ideal candidate brings experience in managed care, healthcare appeals, grievances, or claims processing, along with strong analytical and problem-solving skills. This individual will research claims and supporting documentation, interpret benefit and coverage requirements, communicate case determinations clearly, and collaborate with internal teams to support compliant resolutions and continuous quality improvement.
 
Key responsibilities include:

• Conduct comprehensive reviews, investigations, and resolution of member grievances, appeals, and complaints in accordance with CMS, NCQA, and applicable state regulatory guidelines.
• Research and analyze claims, benefit plans, authorizations, and supporting documentation to determine appropriate case outcomes.
• Ensure all cases are processed within required regulatory and internal timelines.
• Request, review, and interpret medical records, provider documentation, and itemized bills as needed to support case determinations.
• Apply contract language, benefit structures, medical policies, and coverage guidelines when evaluating grievances and appeals.
• Collaborate with internal departments, including Medical Management, Provider Relations, and Compliance, to support accurate and consistent resolutions.
• Identify root causes of issues, including claims processing errors, system configuration discrepancies, and provider billing concerns.
• Prepare clear, concise, and compliant written correspondence to members, providers, and authorized representatives regarding case determinations.
• Document case activity, findings, and outcomes in accordance with audit and regulatory requirements.
• Track and report grievance and appeal trends to support quality improvement initiatives.
• Communicate with members and providers through written and verbal channels to obtain additional information or clarify case details.
• Maintain established departmental productivity and quality performance standards.

REQUIREMENTS:

• Minimum of 2 years of experience in managed care, healthcare appeals, grievances, or claims processing, or an equivalent combination of education and experience.
• Working knowledge of Medicare and/or Medicaid regulations, including CMS guidelines for appeals and grievances.
• Understanding of NCQA standards related to member complaint and appeals processes.
• Experience reviewing claims, including eligibility, coordination of benefits (COB), and denial management.
• Strong analytical and problem-solving skills with excellent attention to detail.
• Excellent written and verbal communication skills, including the ability to prepare regulatory-compliant correspondence.
• Strong organizational and time-management skills with the ability to manage multiple priorities and meet strict deadlines.
• Proficiency in Microsoft Office applications and relevant claims or case management systems.
• Experience working in a managed care organization supporting Medicaid, Medicare Advantage, or Marketplace plans preferred.
• Familiarity with medical terminology, coding, and utilization management processes preferred.
• Prior experience handling complex or escalated grievance and appeals cases preferred.
• Background in a healthcare setting such as a hospital, provider office, or health plan operation preferred.

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

Apply For Job