Specialist, Appeals and Utilization Review

Category

Business Operations

Position Type

Full-Time

Curana Health is a provider of value-based primary care services for the senior living industry, including skilled nursing facilities, assisted & independent living communities, Memory Care units, and affordable senior housing sites. Our 1,000+ clinicians serve more than 1,500 senior living community partners across 34 states, and Curana participates in various innovative CMS programs (including owned-and-operated Accountable Care Organizations and Medicare Advantage plans). With rapid year-over-year growth since our founding in 2021, Curana is setting a new standard in innovative care delivery for seniors with high-risk, complex clinical needs, many of whom have been historically underserved by the healthcare system. Our mission: To radically improve the health, happiness and dignity of senior living residents.

The Specialist, Appeals & Utilization Review supports members and providers by reviewing Organization Determination, Appeals, and Grievance (ODAG) cases and coordinating timely, accurate responses. This role manages intake, documentation, and communication throughout the review process, and ensures all work meets CMS guidelines and contractual timeframes. The specialist acts as a key resource for internal partners and external requestors, helping ensure fair, compliant decisions that support the quality of care for our members.

• Investigate and process intake of Organization Determinations, Appeals, and Grievances (ODAG) in a timely and professional manner, adhering to required timeframes.

• Understand the differences between medical necessity appeals, administrative appeals, claim appeals, and organization determinations.

• Receive, log, track, monitor, and document ODAG requests including the collection of supporting documentation.

• Independently respond to ODAG requests and inquiries.

• Prepare written documentation including outcome letters, acknowledgement letters, and other required correspondence.

• Accurately document all ODAG activity in internal systems, including follow-ups and final outcomes, while maintaining secure and complete documentation files.

• Review incoming appeal/grievance correspondence and request additional information when needed.

• Partner with management and external vendors to resolve complex or escalated ODAG cases.

• Other duties as assigned.

Minimum Qualifications

• High school diploma or GED required.

• Working knowledge of Medicare Advantage.

• Experience supporting Medicare Advantage members, including customer service experience.

• Strong interpersonal, analytical, and conflict resolution skills.

• Positive and approachable communication style.

• Proficient in Microsoft Word and Excel.

• Ability to manage multiple priorities and meet firm deadlines.

• Experience interpreting regulations and applying them to case decisions.

• Ability to work calmly and professionally under pressure.

Preferred Qualifications

• Experience in medical claims adjudication, medical billing, medical terminology, or health services.

• Understanding of QNXT for case processing.

• Knowledge of utilization review or organization determination processes.

• Familiarity with Medicare benefits.

• Experience in long-term care or provider-sponsored health plans.

• Ability to learn new systems and adapt in a changing environment.

We’re thrilled to announce that Curana Health has been named the 147^th fastest growing, privately owned company in the nation on Inc. magazine’s prestigious Inc. 5000 list. Curana also ranked 16^th in the “Healthcare & Medical” industry category and 21^st in Texas.

This recognition underscores Curana Health’s impact in transforming senior housing by supporting operator stability and ensuring seniors receive the high-quality care they deserve.