Grievance & Appeals Coordinator II

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

📋 Description

• Evaluate and address verbal and written claims and authorization grievances/appeals from both providers and members.

• Handle state inquiries related to complaints, grievances, and appeals.

• Assess and manage member and provider grievances and appeals in accordance with relevant regulations, policies, and procedures.

• Review claim grievances for reconsideration and either approve or deny based on determination level or prepare for medical review presentation.

• Prepare cases for medical review when necessary.

• Analyze claim grievances to identify potential quality or access issues.

• Work in collaboration with subject matter experts to gather benefit and/or clinical opinions and interpretations of complex cases.

• Act as a liaison among members, providers, regulatory agencies, and internal staff.

• Communicate with key individuals regarding decisions related to grievances and appeals.

• Serve as a subject matter expert on grievances and appeals.

• Lead the Appeals and Grievance Committee.

• Carry out additional responsibilities as assigned.

• Adhere to all policies and standards.

⛳️ Requirements

• Bachelor’s degree in a relevant field or equivalent experience.

• A minimum of 2 years of experience in claims, contracting, or a related role within a managed care setting.

• Proven experience in investigating and resolving complaints from members and providers.

• Excellent written and verbal communication skills.

• Capability to review and process grievances and appeals from members and providers in compliance with federal, state, and organizational regulations, policies, and procedures.

• Ability to review claim grievances for reconsideration and approve or deny based on determination level or prepare for medical review.

• Skill in identifying whether claim grievances may involve potential quality or access issues.

• Proficiency in collaborating with subject matter experts to obtain benefit and/or clinical opinions and interpretations for complex cases.

🏝️ Benefits

• Health insurance.

• 401K plan.

• Stock purchase options.

• Tuition reimbursement.

• Paid time off in addition to holidays.

• Flexible work arrangements, including remote, hybrid, field, or office schedules.

• Competitive salary.

• Additional incentives may be included in total compensation.