Appeals & Grievance Coordinator

Acentra Health, LLC•UNAVAILABLE, Maine

2d•Remote

About The Position

Acentra Health is seeking an Appeals and Grievance Specialist to research and investigate complaints and appeals, manage case outcomes, and support prompt completion of the resolution process. This remote role has core hours in the Eastern time zone. The specialist assigns mail cases to the appropriate area based on appeal level, communicates with members, providers, and regulatory agencies, and documents inquiries, appeals, and complaints. Cases must be resolved within applicable turnaround times and regulatory, accreditation, or customer requirements. The role also requires adherence to corporate policies, including HIPAA Privacy and Security Rules. Additional duties may be assigned by management.

Requirements

High school diploma or GED.
At least 1 year of customer service experience.
Proficiency in Microsoft Word, Outlook, and other relevant software.
Strong critical-thinking capabilities.
Flexibility and good organizational skills.
Strong interpersonal skills.
Basic data-entry skills.
Excellent customer service skills.
Ability to meet departmental standards.
Ability to review cases and ensure they are set up for the correct level of appeal.
Ability to research and resolve complaint outcomes.
Ability to collaborate effectively.
Excellent written and verbal communication skills.

Nice To Haves

Associate's degree.
Previous experience in the health care industry.

Responsibilities

Assign mail cases to the appropriate area based on appeal level, such as administrative appeal, clinical, or external, for triage.
Prepare verbal and written correspondence, including acknowledgment letters, for members, providers, and regulatory agencies.
Document and log inquiry, appeal, and complaint information.
Resolve cases within required turnaround times.
Ensure inquiries, grievances, and appeals are properly resolved within timelines established by regulatory or accreditation agencies or customer needs.
Read, understand, and follow corporate policies, including HIPAA Privacy and Security Rules.
Perform other education- and experience-related duties as assigned by management.