Grievance and Appeals Coordinator

Summary

Responsible for the research and documentation of written and verbal complaints and appeals filed by members to the respective health plan. The coordinator is responsible for identifying the issues and categorizing and entering the information into a database.


Duties and Responsibilities:

  1. Responsible for handling of assigned appeals and grievances by inputting into appropriate databases, writing acknowledgement letters, obtaining medical records as needed, researching cases, resolving issues and faxing resolution letters while ensuring that regulatory time frames are met.
  2. Works with the Senior Medical Director, QM Medical Director and other clinical staff to ensure that clinical issues are appropriately evaluated
  3. Answers telephone inquiries and maintains a professional level of telephone etiquette
  4. Responds to questions from authorized representatives, providers, and appropriate internal staff regarding grievances and appeals
  5. Works closely with internal departments to resolve and research member and provider reconsideration, contacts providers and external agencies to obtain additional information to adequately resolve and respond to the reconsiderations and grievances.
  6. Responsible for investigating and resolving all priority issues and/or concerns in a timely and efficient manner
  7. Responsible for formulating/implementing and executing all processes, requests, workflows or policies as requested by management in a courteous and efficient manner, including offering a proactive approach to suggestions and recommendations 
  8. Other related duties, as assigned
  9. Actively participates in self-development programs

Minimum Job Requirements:

  • High School graduate or GED equivalent
  • Minimum one year experience working in an appeals and grievances department at health plan, MSO or IPA
  • Attention to detail and accuracy and capability of meeting deadlines consistently

Skills and Abilities:

  • Effective verbal and written communication skills and effective interpersonal skills.
  • Excellent organizational skills and ability to multitask
  • Ability to work well in a busy department
  • Able to stay focused on the telephone even with noise and other distractions
  • Minimum or higher proficiency level with Microsoft Office Programs; primarily Word and Excel 2013 or higher
  • EZ-CAP® knowledge a plus.

Salary Range:

  • $28 - $33 per hr

Apply for Grievance and Appeals Coordinator

Please fill in your information below.

Upload your resumé or CVS (optional).

  • image
  • image

Send an Email

×