Appeals & Grievances Clinical Coordinator

This is a fully remote position, open to applicants in New York.

📋 Description

• Assist the clinical team in ensuring prompt and precise case processing.

• Establish case files for clinical evaluation.

• Conduct research and file appeals, including organizational determination investigations.

• Request and organize member medical records and associated documentation.

• Create written summaries and arrange case schedules.

• Manage case reviews and document the resolutions of appeals.

• Forward complete case files to external review organizations in accordance with regulatory standards.

• Prepare cases by collecting documentation, uploading evidence, and making calls to both members and providers.

• Generate and print letters for determination and authorization notifications.

• Perform data entry and create authorizations within the True Care system.

• Inform the team lead about appeal trends, claim inaccuracies, configuration issues, and systemic challenges.

• Serve as a liaison with providers and members throughout the appeal processing.

• Collaborate with Contact Center Operations, Claims, DSE, and E&B departments.

• Ensure that appeals and grievances are handled within the designated timeframes set by New York State and federal regulations.

• Assemble evidence packages and draft correspondence.

• Request denial files from designated vendors and prepare cases for Clinical Specialist evaluations.

• Maintain the integrity, content, and confidentiality of files.

• Attend meetings and perform other duties as assigned.

⛳️ Requirements

• High School Diploma or GED is required.

• Familiarity with relevant New York State and federal regulations is highly desirable.

• Proficiency in Microsoft Office is essential.

• Understanding of New York State ART 44 PHL and the federal regulatory framework.

• Knowledge of the claims payment process and claims data systems (MHS).

• Ability to work independently as well as collaboratively within a team.

• Proven ability to meet deadlines and demonstrate flexibility to adapt to changing priorities.

🏝️ Benefits

• Comprehensive medical, dental, and vision coverage.

• Incentive and recognition programs.

• Life insurance options.

• 401k contribution plans.

• Competitive compensation and benefits package.