Appeal and Grievance Coordinator

This is a fully remote position, open to applicants in Kentucky, +3 more states.

📋 Description

• Intake, investigate, and resolve appeals, complaints, and grievances across all products.

• Research incoming electronic appeals, complaints, and grievances, and direct inappropriate work items accordingly.

• Analyze plan design and coverage certification to evaluate benefit or administrative denials.

• Examine claim-processing logic, member eligibility, and billing/payment status prior to initiating appeals.

• Identify and investigate all elements of member or provider appeals, complaints, and grievances.

• Direct incomplete elements to the appropriate subject-matter experts in other business units.

• Coordinate all components related to appeals, complaints, and grievances, including final communications and resolution.

• Act as a technical resource for colleagues on complicated issues.

• Recognize and report trends and emerging issues, providing input on potential solutions.

⛳️ Requirements

• Must reside in KY, OK, or OH.

• 1–2 years of experience in areas such as claim platforms, products, and benefits; patient management; product or contract drafting; compliance and regulatory analysis; special investigations; provider relations; customer service; or audit experience.

• Familiarity with reading or researching benefit language.

• Capability to thrive in a fast-paced environment with tight deadlines.

• Ability to make sound decisions based on current policies and guidelines.

• Comprehensive knowledge of member and/or provider appeals, complaints, and grievance policies.

• Strong analytical skills with a focus on accuracy and attention to detail.

• Understanding of clinical terminology, regulatory, and accreditation requirements.

• Exceptional verbal and written communication skills.

• Proficient in computer usage, including Excel and Microsoft Word.

• High school diploma or GED equivalent is required.

• Some college education is preferred.

🏝️ Benefits

• Medical coverage.

• Dental coverage.

• Vision coverage.

• Paid time off.

• Retirement savings options.

• Wellness programs.

• Additional resources to support physical, emotional, and financial well-being, based on eligibility.