Appeals Coordinator (Hybrid)

1199SEIU Funds•New York, NY

2d•Hybrid

About The Position

The Appeals Coordinator partners with the Manager to implement, communicate, and achieve Appeals Department and Fund goals. The role provides guidance to Appeals staff on complex first- and second-level appeals, monitors production, aging, escalations, and call activity, and supports timely resolution of member and operational issues. The Coordinator analyzes performance and trends, shares findings with the Manager, and helps improve the member experience through call monitoring, listening sessions, and coaching.

Requirements

Bachelor’s degree in health care or a related field, or equivalent years of work experience.
At least four years of experience in claims adjudication, health care claims auditing, or benefit administration.
Advanced knowledge of QNXT navigation, including Member, Claims, Provider, and Medical Codes modules.
Extensive knowledge of health claims policies and procedures, eligibility rules, Coordination of Benefits (COB), and 1199SEIU Family of Funds benefits.
Intermediate Microsoft Word and Excel skills.
Strong knowledge of medical claims processing systems (QNXT), medical terminology, ICD 9/10, and CPT codes.
Strong critical-thinking and analytical skills, including troubleshooting and problem-solving abilities.
Effective verbal and written communication skills.
Effective time and project management skills, including prioritization, attention to detail, multitasking, and ability to thrive in a fast-paced environment.

Nice To Haves

At least two years of experience in a healthcare appeals or grievances environment.
Demonstrated quality-control experience and understanding of auditing procedures.

Responsibilities

Provide guidance to Appeals staff on complex first- and second-level appeals.
Monitor daily, weekly, and monthly production, aging, and escalated reports; ensure issues are addressed promptly and appropriately.
Prepare quantitative and qualitative analyses identifying trends and performance strengths or gaps, and report findings to the Manager.
Resolve escalated calls; serve as a liaison between Appeals staff and Appeals Management; troubleshoot, resolve, and follow up on urgent matters.
Monitor calls daily using call management systems, review reports for system issues and repeat calls, and report findings to the Manager.
Partner with the Manager on listening sessions and coaching for phone staff.
Recommend policy and procedure improvements for the Manager’s approval; help train staff on new or modified policies, procedures, and workflows to support compliance with internal and external laws and regulations, including DOL and ERISA requirements.
Partner with other Appeal Coordinators to quality-review appeals, inquiries, and correspondence for compliance with operational procedures and audit guidelines; identify knowledge gaps or retraining needs and ensure data accuracy and DOL compliance.
Communicate with members, providers, vendors, attorneys, and other professionals by email, fax, and telephone about appeals, benefits, policies, procedures, and plan changes or updates.
Perform additional duties and projects as assigned by management.