Grievance and Appeals Specialist

As the Grievance and Appeals Specialist, you will be responsible for independently resolving member and provider grievances and appeals within applicable state Medicaid, federal, contractual, and accreditation timeframes. You will work directly with members, providers, and authorized representatives and collaborate with Utilization Management, Claims, Member Services, Provider Relations, Pharmacy, Quality, and Compliance to achieve fair, accurate, and well-documented outcomes.

You will manage moderately complex cases, support process improvement, and develop procedures and training materials. The Illinois Tailored Care Management Program helps individuals with complex health and social needs transition from nursing facilities and Specialized Mental Health Rehabilitation Facilities (SMHRFs) to community-based living.

Through person-centered care management and coordinated support services, the program empowers members to live more independently and thrive in their communities.