Grievance And Appeals Coordinator

Responsibilities

• Analyze and resolve verbal and written claims, authorization appeals, complaints, grievances, and appeals from members and providers.
• Gather, analyze, and report data related to member and provider complaints, grievances, and appeals to support compliance and quality standards.
• Prepare clear, professional response letters addressing member and provider complaints, grievances, and appeals.
• Maintain accurate and organized files on individual appeals and grievances, ensuring proper documentation and record-keeping.
• Collaborate proactively with management and cross-functional departments to resolve complex cases and improve processes.
• Communicate clearly and professionally with internal teams, members, and providers regarding case status, outcomes, and next steps.
• Support pay-for-performance programs through data entry, tracking, organizing, and researching information related to performance metrics.
• Affiliate with HEDIS production functions, including data entry, outbound calls to provider offices, and claims research to support quality reporting.
• Manage high volumes of documents, including copying, faxing, and scanning incoming mail and case-related materials.
• Research complex cases and compliance-related issues, ensuring decisions align with regulatory requirements and internal policies.
• Complete case reviews and resolutions within required timelines while maintaining high quality standards and attention to detail.
• Contribute to continuous improvement initiatives by identifying trends, issues, and opportunities to enhance grievance and appeals handling.

Essential Skills

• High school diploma or equivalent required; associate degree preferred.
• 2+ years of experience in appeals & grievances, claims, managed care, healthcare administration, or customer service.
• Strong written and verbal communication skills.
• Excellent attention to detail and accuracy.
• Proficiency with digital tools, case management systems, and office software.
• Strong analytical, research, troubleshooting, and problem-solving abilities.
• Ability to manage high workloads and maintain organization in a fast-paced environment.
• Comfortable working remotely and collaborating with cross-functional teams.
• Commitment to quality, compliance, and maintaining high accuracy standards (97%+).

Additional Skills & Qualifications

• Associate’s degree in a related field is preferred.
• Experience working with complex cases or compliance-related tasks in healthcare, insurance, or other regulated environments.
• Knowledge of healthcare regulations, including health plan compliance and regulatory requirements, and familiarity with Medicare/Medicaid guidelines.
• Conflict resolution skills, with the ability to handle sensitive cases with professionalism, empathy, and discretion.
• Project coordination experience, including exposure to coordinating cross-functional projects or initiatives in a fast-paced environment.
• Strong letter-writing skills, with the ability to tailor responses to members and providers while maintaining a professional tone.
• Experience supporting pay-for-performance programs through data entry, tracking, and information research.
• Experience with HEDIS-related functions such as data entry, provider outreach, and claims research.
• Experience with performance metrics and quality indicators, including accuracy, timeliness, and customer satisfaction.
• Demonstrated reliability and commitment to longer-term roles, with an interest in potential conversion from contract to permanent employment.