Appeals and Grievance Coord II

Leon Medical Centers • Doral, FL

9d

About The Position

The Appeals and Grievance Coordinator coordinates the intake and processing of member and provider appeal and grievance requests. The role researches case information across designated databases, prepares documentation and case files for Independent Review Entities and other escalated cases, and supports specialists with case resolutions. The coordinator helps ensure cases are acknowledged, resolved, communicated, and effectuated within applicable state and federal regulatory timeframes while providing courteous, timely support to members and providers.

Requirements

• Bachelor’s degree in business or a related field.
• Two years of experience in a managed care environment in grievance or appeals, claims, or related work, or an equivalent combination of training and experience.
• Fluency in English and Spanish.

Responsibilities

• Coordinate intake of appeal and grievance requests from members and providers into designated systems.
• Generate acknowledgement letters for appellants and answer general appeal-status questions.
• Compile case files to be sent to an Independent Review Entity (IRE).
• Ensure adherence to state and federal regulatory timeframes, including acknowledging and resolving cases, monitoring effectuation of resolutions, completing resolution letters, and communicating with members and providers.
• Prepare case files for Independent Review Entities and other escalated cases, including Statements of Position and case narratives.
• Develop grievance and appeal request information from designated databases.
• Assist Investigation and Appeals Specialists with appeal and grievance resolutions.
• Develop and maintain positive customer relations and coordinate with company functions to handle customer requests and questions appropriately and promptly.
• Demonstrate courtesy and politeness to patients, visitors, callers, and other employees.

What This Job Offers

• Job Type: Full-time