Appeals & Grievance Coordinator

This is a fully remote position, open to applicants in United States.

📋 Description

• Monitor and analyze all grievances, appeals, and complaints received by the Member Services Department.

• Serve as the main investigator and point of contact for member and provider grievances and appeals.

• Acknowledge the receipt of grievances, appeals, and CTM complaints.

• Collect pertinent information and determine suitable resolutions in accordance with policies and procedures.

• Inform relevant parties of resolutions and ensure the completion of internal processes.

• Draft written communication to members in line with plan policies and CMS Guidelines.

• Conduct thorough, unbiased, and timely investigations.

• Record all actions undertaken to resolve grievances and appeals.

• Ensure processing complies with CMS guidelines and plan policies.

• Prepare case files for the Medical Director and external reviews, including IRE review.

• Compile case histories for committee and Board of Directors meetings.

• Maintain comprehensive and timely documentation of grievances and appeals.

• Generate monthly and quarterly reports.

• Identify training needs and opportunities for system or process enhancements.

• Participate in policy and procedure evaluations, CMS audit preparations, and regulatory meetings/interviews.

• Perform additional duties as assigned.

⛳️ Requirements

• A minimum of two years of experience in data entry and general office settings.

• At least three years of customer service experience.

• A minimum of one year in Member Services or a related field.

• High School Diploma or GED required.

• Familiarity with MediCal and Medicare Managed Care Plans.

• Proficiency in keyboarding at a speed of 40+ words per minute.

• Ability to utilize the 10-key by touch.

• Strong written and verbal communication skills.

• Capability to build and maintain constructive relationships with diverse members, management, employees, and vendors.

• Competence in reading and interpreting safety regulations, operating instructions, and procedure manuals.

• Ability to compose routine reports and correspondence.

• Skill in effectively speaking before groups of customers or employees.

• Proficiency in performing basic arithmetic with American currency and measurements of weight, volume, and distance.

• Strong problem-solving, organizational, and time-management abilities.

• Capacity to thrive in a fast-paced environment.

• Availability to work weekends is required.

🏝️ Benefits

• Fully remote work opportunity.

• Potential for growth and innovation.

• Reasonable accommodations for individuals with disabilities.

• Commitment to equal opportunity employment.