Senior Coordinator, Complaint Appeals - Remote

Position Summary

Responsible for managing to resolution appeal scenarios for all products, which contain multiple issues and may require coordination of responses from multiple business units. Appeals are typically more complex and may require outreach and deviation from standard processes to complete. Develop into a subject matter expert by providing training, coaching, or responding to complex issues. May have contact with outside plan sponsors or regulators.

Responsibilities

• Research and resolves incoming electronic appeals as appropriate as a "single-point-of-contact" based on type of appeal.
• Identify and reroute inappropriate work items that do not meet complaint/appeal criteria as well as identify trends in misrouted work.
• Assemble all data used in making denial determinations and can act as subject matter expert with regards to unit workflows, fiduciary responsibility and appeals processes and procedures.
• Research standard plan design, certification of coverage and potential contractual deviations to determine the accuracy and appropriateness of a benefit/administrative denial.
• Review a clinical determination and understand rationale for decision.
• Research claim processing logic and various systems to verify accuracy of claim payment, member eligibility data, billing/payment status, and prior to initiation of the appeal process.
• Coordinate efforts both internally and across departments to successfully resolve claims research, SPD/COC interpretation, letter content, state or federal regulatory language, triaging of complaint/appeal issues, and similar situations requiring a higher level of expertise.
• Identify trends and emerging issues and report on and give input on potential solutions.
• Deliver internal quality reviews, provide appropriate support in third party audits, customer meetings, regulatory meetings and consultant meetings when required.
• Understand and respond to Executive complaints and appeals, Department of Insurance, Department of Health or Attorney General complaints or appeals on behalf of members or providers as assigned.

Required Qualifications

• 1-2 years Medicare part C Appeals experience.
• Experience in reading or researching benefit language in SPDs or COCs.
• Experience in research and analysis of claim processing a plus.
• Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
• Excellent verbal and written communication skills.
• Excellent customer service skills.
• Experience documenting workflows and reengineering efforts.

Preferred Qualifications

• Strong knowledge of all case types including all specialty case types
• Project management skills are preferred.

Education

High School Diploma

Pay

The typical pay range for this role is $18.50 - $35.29. This pay range represents the base hourly rate or base annual full-time salary for all positions in the job grade within which this position falls. The actual base salary offer will depend on a variety of factors including experience, education, geography and other relevant factors.

Schedule

Anticipated Weekly Hours: 40. Time Type: Full time.

Benefits

This full‑time position is eligible for a comprehensive benefits package designed to support the physical, emotional, and financial well‑being of colleagues and their families. The benefits for this position include medical, dental, and vision coverage, paid time off, retirement savings options, wellness programs, and other resources, based on eligibility.