JOB SUMMARY

The Appeals and Grievance Coordinator is responsible for intake into the Appeals and Grievances Department, including verbal and written complaints, grievances and requests for appeals that involve complex matters submitted by Members and Providers. This position will perform comprehensive research to clarify facts and circumstances in order to accept cases into inventory.

ESSENTIAL FUNCTIONS OF THE ROLE

• Intakes and processes written and fax referred cases from member and provider appeals and complaints for all lines of business, ensuring compliance with applicable policies and procedures and other governing bodies. Communicates with members and providers verbally and in writing.
• Maintains required documentation to assure meeting regulatory requirements on intake processes (e.g. acknowledgement letters; waiver of liability requirements). Tracks information to facilitate and expedite processing of appeals received.
• Assures that assigned work processes are on track and in line with regulatory required turn around time for the activity as assigned.
• Maintains mailing process tracking of the Medicare mailed correspondence. Assures letters are delivered to the mailroom in timely fashion.
• Assists with audit preparation as needed by management.

KEY SUCCESS FACTORS

• Requires current knowledge of all regulatory requirements as they apply to complaint, grievance and appeal processes.
• Proficient in Microsoft applications, including Word and Excel.
• Ability to effectively interact with customers to understand their needs and explain data.
• Proven written and communication skills.
• Critical thinking and listening skills.

BENEFITS

Our competitive benefits package includes the following

• Immediate eligibility for health and welfare benefits
• 401(k) savings plan with dollar-for-dollar match up to 5%
• Tuition Reimbursement
• PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

• EDUCATION - H.S. Diploma/GED Equivalent
• EXPERIENCE - 2 Years of Experience