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Role Description

The Appeal & Grievance Coordinator will receive, investigate, and triage expedited appeal requests from members and provider representatives enrolled in Senior Products. Timely assignment of cases is critical to ensure that appeal rights are processed in accordance with regulatory standards, including the Center for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA).

• Claims research and processing (more focused on understanding why claims were denied)
• Authorization lookup/building authorizations and updating them
• Researching outside vendor sites for authorizations and reviewing notes
• Reviewing appeal letters to determine the basis of the provider's appeal
• Starting the appeal process and conducting research on the appeal
• Sending out appeal determination letters and completing the appeal
• Extensive training on internal and external systems and the internal appeal process

Qualifications

• At least 1 year of experience in health insurance claims and appeals is strongly preferred
• At least a high school degree; a college degree and/or extensive experience would be considered
• Outbound call experience (though not a large part of this job) is a plus
• A customer service background and experience, not necessarily in the healthcare field, is a nice to have
• Medicaid experience desired and will make the candidate stand out