Job Description
Seeking a detail-oriented Appeal and Grievance Coordinator to support the intake, research, classification, and processing of member and provider appeals and grievances for Senior Products. This role is responsible for ensuring expedited and standard appeals are handled accurately and within regulatory timeframes established by CMS, NCQA, and other state and federal agencies. The ideal candidate will have experience in health insurance claims, provider appeals, and working within fast-paced healthcare environments requiring strong analytical and organizational skills.
RESPONSIBILITIES
• Receive, research, investigate, and triage expedited and standard appeal requests from members, providers, and representatives.
• Review appeal letters and supporting documentation to determine the nature of the provider or member dispute.
• Initiate and manage the appeal process from intake through resolution and determination.
• Conduct claims research, including identifying reasons for claim denials and reviewing related documentation.
• Research and update authorizations through internal systems and external vendor portals.
• Review notes and documentation from outside vendors and internal departments to support appeal processing.
• Prepare and send appeal determination letters in accordance with regulatory requirements and internal procedures.
• Accurately input and verify case information within designated systems while maintaining data integrity.
• Analyze billed charges and determine appropriate place of service classifications.
• Navigate multiple internal and external systems to complete case intake and resolution activities efficiently.
• Process cases across various lines of business including Medicare, Medicaid, and DSNP products.
• Ensure compliance with all CMS, NCQA, state, and federal regulations governing appeals and grievances.
• Maintain productivity and quality standards while managing a high-volume caseload.
REQUIRED QUALIFICATIONS
• U.S. Citizenship required.
• High School Diploma or equivalent required.
• Minimum of 1 year of experience in health insurance claims and provider appeals.
• Ability to manage and process approximately 50 intake cases daily with strong accuracy and attention to detail.
• Strong analytical, organizational, and problem-solving skills.
• Ability to work effectively across multiple systems and applications simultaneously.
PREFERRED QUALIFICATIONS
• Bachelor’s Degree preferred.
• 3 years of healthcare, claims, or appeals experience.
• Medicaid experience strongly preferred.
• Customer service experience, including outbound call experience, preferred.
• Experience working with Medicare, Medicaid, and DSNP products.
• Familiarity with healthcare regulatory requirements and appeal processes.
REMOTE WORK ELIGIBILITY:
• This position is fully remote; however, candidates must permanently reside in the United States to be eligible.
• All work must be conducted within the continental U.S.
• Applicants outside of the U.S. cannot be considered for this position.
• No C2C, sponsorship, or relocation available for this role.
RESPONSIBILITIES
• Receive, research, investigate, and triage expedited and standard appeal requests from members, providers, and representatives.
• Review appeal letters and supporting documentation to determine the nature of the provider or member dispute.
• Initiate and manage the appeal process from intake through resolution and determination.
• Conduct claims research, including identifying reasons for claim denials and reviewing related documentation.
• Research and update authorizations through internal systems and external vendor portals.
• Review notes and documentation from outside vendors and internal departments to support appeal processing.
• Prepare and send appeal determination letters in accordance with regulatory requirements and internal procedures.
• Accurately input and verify case information within designated systems while maintaining data integrity.
• Analyze billed charges and determine appropriate place of service classifications.
• Navigate multiple internal and external systems to complete case intake and resolution activities efficiently.
• Process cases across various lines of business including Medicare, Medicaid, and DSNP products.
• Ensure compliance with all CMS, NCQA, state, and federal regulations governing appeals and grievances.
• Maintain productivity and quality standards while managing a high-volume caseload.
REQUIRED QUALIFICATIONS
• U.S. Citizenship required.
• High School Diploma or equivalent required.
• Minimum of 1 year of experience in health insurance claims and provider appeals.
• Ability to manage and process approximately 50 intake cases daily with strong accuracy and attention to detail.
• Strong analytical, organizational, and problem-solving skills.
• Ability to work effectively across multiple systems and applications simultaneously.
PREFERRED QUALIFICATIONS
• Bachelor’s Degree preferred.
• 3 years of healthcare, claims, or appeals experience.
• Medicaid experience strongly preferred.
• Customer service experience, including outbound call experience, preferred.
• Experience working with Medicare, Medicaid, and DSNP products.
• Familiarity with healthcare regulatory requirements and appeal processes.
REMOTE WORK ELIGIBILITY:
• This position is fully remote; however, candidates must permanently reside in the United States to be eligible.
• All work must be conducted within the continental U.S.
• Applicants outside of the U.S. cannot be considered for this position.
• No C2C, sponsorship, or relocation available for this role.
Additional Details
Experience: 2-5 years