Appeals & Grievances Coordinator

WebTPA • FL, FL

1d • $20 - $33

About The Position

The Medicare Appeals & Grievances Coordinator resolves Medicare member, member representative, and non-participating provider appeals and grievances in compliance with applicable CMS timeframes and regulations. The role prioritizes case inventory to meet CMS and OIR service-level requirements, gathers relevant information and medical records, coordinates with appellants and delegated vendors, tracks effectuations, and meets written and oral notification requirements.

The coordinator reviews and classifies appeals and grievances, identifies potential expedited requests, researches cases, documents supporting information and actions taken, and works with internal business partners and external parties to reach final determinations. The position handles cases involving dissatisfaction, reimbursement, medical necessity, utilization management, benefits, and payment disputes, and performs outreach to members, providers, and business partners. It also facilitates escalated calls and issues, escalating to the Manager as needed.

The role uses multiple Medicare and business systems to gather case information and document resolutions. Work schedules are based on role requirements and business needs; travel to and from corporate offices may be required. The position is sedentary, with occasional exertion of up to 10 pounds to move objects.

Requirements

• At least 3 years of related work 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, as well as 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, ProviderConnect, CustomerConnect, Client Letter, ERCMS RADMD, Magellan, and Blue 2.

Responsibilities

• Review appeal and grievance cases from members, member representatives, treating physicians, and non-participating providers according to CMS guidelines and timeframes.
• Classify cases correctly and review them for potential expedited requests.
• Resolve complex standard or expedited grievances, appeals, and disputes involving dissatisfaction, reimbursement, medical necessity, utilization management, and benefits.
• Prioritize workload to meet CMS timeframes and written-notification requirements for standard pre-service appeals, expedited pre-service appeals, post-service appeals, payment disputes, MA grievances, and Med Supp grievances.
• Use systems including MAAGC, JIVA, Diamond, ProviderConnect, Client Letter, ERCMS RADMD, Magellan, and Blue 2 to gather case information and document resolutions.
• Research cases thoroughly, document relevant details and actions taken, conduct outreach to business partners, and attach supporting documents.
• Coordinate with internal business partners and gather required data or medical records for cases involving clinical decisions, delegated vendors, claims, and network matters.
• Complete research and document supporting details to render final determinations, providing verbal and/or written notification to appellants within CMS timeframes.
• Conduct outreach to members, providers, and internal and external business partners to resolve appeals and grievances.
• Facilitate escalated calls and issues from providers or members regarding appeals or dispute decisions, and escalate issues or calls to the Manager as needed.

Benefits

• Medical, dental, vision, life, and global travel health insurance.
• Income protection benefits, including life insurance and short- and long-term disability programs.
• Leave programs to support personal circumstances.
• Retirement Savings Plan with employer match.
• Paid time off, 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: High school or GED