Senior Grievace and Appeals Coordinator

Responsibilities

• Review, investigate, and process member and provider grievances and appeals in accordance with regulatory timelines.
• Maintain accurate case documentation and tracking logs.
• Cook with Medical Directors, Claims, Provider Relations, Pharmacy, and other internal departments to facilitate timely case resolution.
• Prepare written correspondence to members, providers, and regulatory agencies.
• Monitor appeal deadlines and ensure compliance with CMS, DOH, and contractual requirements.
• Assist with Fair Hearings, External Appeals, and Independent Review Entity (IRE) cases as needed.
• Analyze case information and escalate complex issues appropriately.
• Support audit readiness by maintaining complete and accurate records.
• Participate in quality improvement initiatives and process enhancements.

Qualifications

• Bachelor's degree in Healthcare, Human Services, Business Administration, or a related field preferred (or equivalent experience).
• Minimum 2 years of Grievance & Appeals experience in a Medicare and/or Medicaid Managed Care environment required.
• Strong knowledge of CMS, Medicare, Medicaid, and New York State regulatory requirements.
• Excellent written and verbal communication skills.
• Strong organizational and analytical abilities with attention to detail.
• Proficiency in Microsoft Office.
• Experience with FACETS is preferred.