Grievance and Appeals Coordinator - Medical Professionals

Are you passionate about ensuring fair and equitable outcomes for members? We are looking for a dedicated Grievance and Appeals Specialist to support our team in navigating complex cases and fostering positive relationships with members and providers.

Responsibilities:

• Assist the Grievance and Appeals Intake Specialist during high-volume periods to ensure timely intake and prioritization of cases
• Ensure all grievance and appeal cases are complete and compliant with necessary documentation, paying special attention to expedited cases
• Use sound judgment to assess issues within cases, ensuring adherence to state and federal regulations
• Produce and manage outbound correspondence and reports, meeting regulatory timeframes
• Build and maintain professional relationships with internal teams and external partners, communicating effectively both orally and in writing
• Perform accurate and consistent data entry in accordance with policies and procedure
• Reach out to members and providers to collect necessary information for case resolution
• Attend and engage in committee and departmental meetings, training, and coaching sessions

Qualifications:

• High School Diploma or GED
• Associates Degree or equivalent
• 2+ years of experience in Customer Service or provider service in a managed care setting
• Knowledge of health plan benefits, processes, and operations