Member Appeals & Grievances Coordinator

Pay Rate: $18 to $24 per hour

Summary:

• The Member Appeals and Grievances (A&G) Coordinator performs administrative functions associated with incoming Member Appeals and Grievances.
• Responsible for identification, intake, and distribution of member appeals and grievances.
• Maintains organized, secure, and efficient record keeping processes.
• Responds to other business areas and members/providers regarding status of appeals and grievances or A&G processes in a timely and professional manner.
• Establishes and maintains collaborative and meaningful interdepartmental relationships.

Responsibilities:

• Appropriate and compliant identification of appeals and grievances during intake.
• Accurate and detailed entry into the A&G system of record.
• Timely distribution of all appeals and grievances to the Appeals and Grievances Specialists in accordance with department rules and deadlines.
• Responsible for data accuracy during entry into the A&G system of record to support the integrity of trend analysis and reporting.
• Development and management of appropriate workflows to minimize manual errors and ensure compliance and consistency.
• Identifying trends and/or areas of concern to be raised to the A&G Management team.
• Assist with audits and reporting needs as necessary and applicable.
• Participation in the creation of daily, weekly, and/or monthly reports for the A&G Management team as part of the internal auditing and monitoring program.
• Participate in or lead training with the A&G Management team, A&G Specialists, and/or new Coordinator staff.
• Meets all required deadlines for entry into the A&G system of record, responses to inquiries from other departments, and return telephone calls/voicemails.
• Other appeals and grievances support duties as assigned.

Requirements:

• Bachelor’s degree in Health Care Administration, related field, or an equivalent combination of education, training, and experience.
• Experience with Microsoft Office Applications.
• Demonstrated ability to use proprietary healthcare management systems.
• Proven ability to identify problems and procedural irregularities, collect data, establish facts, and draw valid conclusions.

Preferred Skills:

• Experience with JIVA, Facets, and HPMS.
• Access experience.
• Minimum 2 years of experience in a healthcare setting, specifically related to Appeals and Grievances.
• Experience with data entry, trend analysis, and reporting.
• Experience with health insurance (Commercial, Medicaid, and Medicare).
• Experience with rules and regulations governing health insurance (Commercial, Medicaid, and Medicare).
• Experience communicating with a provider network.
• Certified Professional Coder (CPC) certification.

Competencies, Skills, and Attributes:

• Excellent attention to detail and organizational skills.
• Excellent oral, written, and interpersonal communication skills.
• Ability to be flexible and work independently, as well as collaborate with other departments across the organization.
• Ability to work effectively in a fast-paced environment.
• Problem-solving skills.
• Ability to abstract data, analyze, and identify trends.
• Ability to multitask.
• Ability to provide high-quality customer service.

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Flexibility to work some evening/weekend hours if necessary.
• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.