Appeals & Grievances Coordinator

Principal Duties And Responsibilities

• Handle a large volume of incoming appeals (both formal and informal) from receipt through resolution, ensuring that all grievances are resolved within contractual and regulatory timeframes.
• Ensure accurate time management of all work, ensuring results are met on time with high-quality standards.
• Document and supervise all grievances in the appropriate tracking systems, ensuring the highest quality and accuracy of work.
• Ensure grievance files are complete and contain all relevant documentation, including research materials, acknowledgment and resolution letters, and any other pertinent information related to the case.
• Collaborate with key departments on all grievances, including Compliance, Pharmacy, Medical Directors, Sales, and other relevant senior and executive staff.
• Aids in the preparation of reports to various collaborators and provide feedback on ways which reporting can be enhanced and improved.
• Stay ahead of any changes to health plan policies and procedures and work closely with key partners on ensuring that the files being prepared for external agencies are accurate, well-written, and meet the needs of all parties.

Qualifications

• Education: High School Diploma required; Bachelor's Degree preferred.
• Experience: At least 3-5 years of health plan experience, ideally within customer service, quality, or appeals and grievances areas preferred. Experience leading appeals and grievances for Medicare products and plans is highly preferred.
• Knowledge, Skills, And Abilities: Strong aptitude for technology-based solutions. Strong customer service skills. Excellent communication skills. Ability to adapt to changing priorities and work effectively in a dynamic environment. Excellent organizational abilities to manage multiple tasks, prioritize work, and meet deadlines.