Job Summary:
The Paralegal II - Quality Appeals & Grievances provides legal, analytical, and operational support to the Quality Appeals and Grievances function. The role conducts research, reviews appeal and grievance determinations, analyzes external review outcomes, prepares reports, and supports regulatory compliance activities. The Paralegal I assists with drafting responses, auditing appeal documentation, and providing insights to support quality improvement and regulatory readiness under the guidance of department leadership.
Essential Functions:
- Provide paralegal, research, and administrative support to Quality Appeals & Grievances leadership and team members.
- Respond to internal and external inquiries as directed, with appropriate review and oversight.
- Initiate, gather, and analyze information related to internal appeal decisions.
- Conduct research utilizing legal databases, regulatory guidance, industry resources, and approved organizational technologies to support appeal determinations and rebuttal preparation.
- Research, analyze, and support the preparation of responses, documentation, and supporting records related to External Reviews, Fair Hearings, audits, and regulatory inquiries.
- Analyze internal and external appeal outcomes, identify trends, and prepare reports and dashboards related to case volume, overturn rates, review findings, reviewer qualifications, and other key performance indicators.
- Develop and deliver weekly, monthly, and quarterly reports based on appeal and review data.
- Audit Final Adverse Determination (FAD) letters and other appeal and grievance determinations to ensure regulatory compliance and quality standards are met.
- Identify trends, risks, and opportunities for process improvement and communicate findings to department leadership.
- Provide feedback to the Clinical Coordinator and department leadership as directed.
- Perform administrative duties as delegated by the department head.
- Assist with departmental initiatives and special projects as assigned
- Perform any other job related duties as requested.
Education and Experience:
- High School or GED required
- Associates degree preferred
- Two (2) years paralegal, legal support, managed care, healthcare compliance, appeals, grievances, or related experience required
Competencies, Knowledge and Skills:
- Proficiency in Microsoft Office Suite, including Word, Excel, PowerPoint, and other business applications
- Working knowledge of legal research tools, regulatory resources, and industry guidance applicable to appeals, grievances, external reviews, and fair hearings
- Knowledge of applicable healthcare regulations, regulatory requirements, accreditation standards, and organizational policies related to appeals and grievances
- Working knowledge of managed care, healthcare operations, and appeals and grievance processes
- Strong analytical, critical thinking, and research skills with the ability to evaluate complex information, identify trends, and develop meaningful insights
- Ability to conduct quality assurance reviews, audits, and compliance monitoring activities to ensure accuracy, consistency, and regulatory compliance
- Ability to collect, analyze, interpret, and present data to support reporting, decision-making, quality improvement, and operational objectives
- Strong written and verbal communication skills with the ability to prepare reports, correspondence, rebuttals, and other business documentation
- Demonstrated customer service focus and ability to build collaborative working relationships with internal and external stakeholders
- Strong organizational skills with the ability to manage multiple priorities, meet deadlines, and maintain attention to detail in a fast-paced environment
- Ability to utilize approved technology and AI-enabled tools to improve efficiency, accuracy, and overall work outcomes
- Ability to work independently within established guidelines, exercise sound judgment, and accept constructive feedback
Licensure and Certification:
- Paralegal Certificate required
Working Conditions:
- General office environment; may be required to sit or stand for extended periods of time
- May be required to work additional hours and/or outside normal business hours as needed to meet deadlines.
- Travel is not typically required
Compensation Range:
$54,500.00 - $87,300.00
CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
Hourly
Organization Level Competencies
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
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