Appeals & Grievances Coordinator

GuideWell•Jacksonville, FL

2d•Hybrid

About The Position

The Appeals & Grievances Coordinator resolves member, member representative, treating physician, and non-participating provider appeals and grievances in compliance with applicable regulations and required timeframes. The role prioritizes case inventory to meet service-level agreements, gathers case information, coordinates collection of medical records, tracks effectuations, and meets written and oral notification requirements. The coordinator reviews and resolves standard and expedited cases, including complex grievances, appeals, and disputes involving dissatisfaction, reimbursement, medical necessity, utilization management, or benefits. The role conducts research, documents findings and actions, coordinates with internal business partners and delegated vendors, and provides verbal or written determinations to appellants within required timeframes. It also includes outreach to members, providers, and business partners, as well as handling escalated calls and issues and referring matters to the Manager when needed. This position uses various systems and databases, including MAAGC, JIVA, Diamond, Siebel, ProviderConnect, Client Letter, ERCMS, RADMD, Magellan, and Blue 2. It offers a hybrid work arrangement combining flexibility with in-office engagement; team schedules depend on role requirements and business needs, and travel to corporate or regional offices may be required.

Requirements

At least 3 years of related work experience, with experience in Member Contact, Enrollment, Maintenance and Billing (EM&B), Claims, or Medicare.
High school diploma or GED.
Experience using Siebel, Diamond, JIVA, and other Medicare databases.
Ability to work a flexible schedule, including overtime and weekends when needed.
Medicare product knowledge.
Ability to work independently and collaboratively as a team member.
Excellent interpersonal skills and ability to recognize, understand, and respond to sensitive member issues or concerns.
Ability to manage multiple priorities, with analytical and problem-solving skills and attention to detail.

Nice To Haves

Bachelor’s degree.
Strong working knowledge of Medicare Advantage, Supplement, and Frozen Products, CMS, OIR, DFS, and other regulatory requirements.
Proven organizational skills and strong attention to detail.
Ability to work independently and collaboratively and use appropriate judgment to make independent decisions by following guidelines.
Intermediate PC skills, including MS Word, Excel, and PowerPoint.
Hands-on experience processing Medicare Claims, Written Inquiries, or EMB transactions.
Current experience with JIVA, Diamond, Siebel, Provider Connect, Customer Connect Client Letter, ERCMS, RADMD, Magellan, and Blue 2.

Responsibilities

Review appeal and grievance cases from members, member representatives, treating physicians, and non-participating providers in accordance with regulatory guidelines and timeframes; classify cases correctly and review for potential expedited requests.
Resolve complex standard or expedited grievances, appeals, and disputes involving dissatisfaction, reimbursement, medical necessity, utilization management, or benefits.
Prioritize case workload to meet required timeframes and written notification requirements.
Use applicable systems to gather case data and document resolutions.
Conduct thorough research, document relevant details and actions, and attach supporting documents to cases.
Coordinate with internal business partners and delegated vendors to gather required information and medical records for cases involving clinical decisions, claims, network matters, and other issues.
Complete appropriate research and document supporting details to reach final determinations, with verbal and/or written notification to appellants within required timeframes.
Contact members, providers, and internal or external business partners to resolve appeals and grievances.
Facilitate escalated provider or member calls and issues regarding appeals or dispute decisions; escalate issues or calls to the Manager as needed.
Track effectuations.

Benefits

Medical, dental, vision, life, and global travel health insurance.
Short- and long-term disability programs.
Leave programs to support personal circumstances.
Retirement Savings Plan with employer match.
Paid time off and volunteer time off.
10 holidays and 2 well-being days.
Additional voluntary benefits.
Comprehensive wellness program.
Competitive pay and opportunities for incentive or commission compensation.
Regular annual reviews with pay-for-performance considerations for base pay increases.