Lead Grievance & Appeals Coordinator

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

📋 Description

• Offer guidance and support for the daily operations of the appeals function.

• Provide consultation for resolving issues faced by appeals staff.

• Oversee team work output to ensure compliance with internal and NCQA standards.

• Manage a reduced caseload in a lead role.

• Deliver updates on daily case completions, error management, and overall team status.

• Conduct daily huddles to facilitate team communication.

• Contribute to the development of job aids, Q&As, and process modifications.

• Mentor and coach staff members.

• Assist with the state fair hearing process as required.

• Identify needs for training, process enhancements, and resource allocation.

• Suggest action plans to management for improvement.

• Review denial and appeal letters to ensure they contain appropriate content and messaging.

• Prepare for state and health plan audits effectively.

• Address complaints and requests concerning state fair hearing documentation.

• Generate monthly reports, logs, and fulfill other health plan or state contractual obligations.

• Assess and monitor team workload and output for efficiency and accuracy.

• Act as the main point of contact for member, provider, and internal team inquiries.

• Train and inform both new and existing team members on processes, policies, procedures, contracts, and market requirements.

• Execute other assigned duties as necessary.

• Adhere to all relevant policies and standards.

⛳️ Requirements

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

• Minimum of 2 years of experience in grievance and appeals within a Healthcare or Managed Care environment.

• Familiarity with healthcare or managed care grievance and appeals processes.

• Capability to work Monday–Friday, from 8 AM to 5 PM Central Time Zone.

• Willingness to work overtime when needed during the week.

• Availability for on-call duties approximately every other weekend.

🏝️ Benefits

• Competitive salary.

• Health insurance coverage.

• 401K retirement plan.

• Stock purchase options.

• Tuition reimbursement program.

• Paid time off in addition to holidays.

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

• Additional incentive options may be included in total compensation.