Appeal and Grievance Coordinator Reviewer

Job Summary:
Support medical and pharmacy appeals and grievances by researching cases, reviewing medical records, claims, coverage guidelines, and historical data, and ensuring timely and accurate resolution in accordance with applicable regulatory and client requirements.

Key Responsibilities:

• Research and process medical/pharmacy appeals and grievances.
• Review medical records, claims, benefits, and coverage guidelines.
• Research cases using multiple claims and medical management systems.
• Prepare documentation and case files for clinical staff and Medical Directors.
• Process claim corrections and adjustments related to appeals.
• Monitor appeals for trends, missing information, and processing issues.
• Assist with pharmacy appeals, grievance requests, and Level 2/external cases.
• Communicate with members, providers, vendors, and internal departments as needed.
• Maintain HIPAA/PHI confidentiality and follow regulatory requirements.
• Assist with quality audits, reporting, training, and maintaining procedures.

Required Qualifications:

• High school diploma or higher.
• Minimum 1 year of experience in claims processing, medical/pharmacy precertification, appeals & grievances, or related healthcare operations.
• Strong research, analytical, written communication, and customer service skills.
• Experience with Microsoft Office and multiple computer systems.
• Ability to interpret healthcare policies, procedures, and guidelines.

Preferred: Experience with healthcare claims, pharmacy, appeals/grievances, or medical terminology; bachelor’s degree in healthcare/business is a plus.