Appeals & Grievances Coordinator
Job Summary The Appeals and Grievance (A&G) Coordinator plays an essential role in assisting with the operational aspects of the Appeals and Grievances process, ensuring compliance with State and Federal regulations. This role includes a variety of responsibilities, such as processing daily mail, managing case distribution, gathering necessary information from external vendors, coordinating medical record requests, tracking progress, and ensuring appeals and related information are delivered to key departments and committees. The A&G Coordinator will also analyze department processes, report data, identify trends, and ensure timely and compliant handling of Medicare Part D Appeals and Fast Track Appeals according to CMS regulations. The coordinator must have a solid understanding of all lines of business and benefit structures, as well as regulatory requirements and timelines. Interaction with providers and other internal and external stakeholders will be frequent, requiring strong communication and organizational skills. Key Responsibilities/Duties – What You Will Be Doing
- Assign new verbal and written appeals and grievances to A&G Analysts
- Process Fast Track Appeals, including monitoring the phone line and fax for new cases, and act as a liaison between A&G, Care Management, and the Independent Review Organization (IRO)
- Support A&G Analysts in completing Appeals and Grievances in a timely manner
- Ensure all work adheres to regulatory and compliance deadlines
- Manage the distribution of incoming mail and manual processing for the department
- Take on additional duties and projects as needed
Qualifications – What You Need to Perform the Job Education, Certification, and Licensure:
- Associate's Degree or equivalent experience in healthcare, conflict resolution, or a related field
Experience (minimum years required):
- 1-2 years of experience in healthcare or administrative settings is preferred
Skill Requirements:
- Strong organizational and communication skills
- Proficient in Microsoft Excel and Word, with experience using Windows applications and other comparable systems
- Basic medical terminology knowledge is a plus
- Ability to identify urgent situations and follow appropriate protocols
- Capable of managing multiple priorities in a fast-paced, high-pressure environment
- Excellent analytical, problem-solving, and attention-to-detail skills
- Ability to work independently and as part of a team, while knowing when to ask for assistance
- Flexibility to adapt to changing department needs
Working Conditions and Additional Requirements:
- Ability to work in a typical office environment or remotely as needed
- Use of a telephone/headset and laptop/keyboard while sitting for extended periods
- Occasional work beyond standard hours may be required, including weekends or evenings depending on business needs