Appeals & Grievances Coordinator

Florida Blue (Blue Cross and Blue Shield of Florida) • Jacksonville, FL

2d • $20 - $33 • 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 timeframes. The role prioritizes case inventory to meet service-level requirements, gathers case information and medical records, coordinates with appellants and delegated vendors, tracks effectuations, and meets written and oral notification requirements.

The coordinator reviews, classifies, researches, and resolves standard and expedited appeals, grievances, and disputes involving dissatisfaction, reimbursement, medical necessity, Utilization Management, and benefits. The position requires outreach to members, providers, and internal and external business partners, accurate documentation of research and actions, and coordination to obtain data and records needed for determinations. It also handles escalated provider and member calls and refers issues to the Manager as needed.

This position offers a hybrid work arrangement combining in-office engagement with flexibility. Schedules depend on role requirements and business needs, and travel to corporate or regional offices may be required. The role is sedentary, with occasional exertion of up to 10 pounds to move objects.

The hourly pay range is $20–$33, with a typical hourly range of $20–$25. Final pay depends on market competitiveness, internal equity, and job-related knowledge, skills, training, and experience.

Requirements

• At least 3 years of related work experience, including 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 and demonstrate analytical and problem-solving skills with 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 EM&B 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 them for potential expedited requests.
• Resolve complex standard or expedited grievances, appeals, and disputes involving dissatisfaction, reimbursement, medical necessity, Utilization Management, and benefits.
• Prioritize case workload to meet required timeframes and written notification requirements for different case types.
• Use systems including MAAGC, JIVA, Diamond, Siebel, ProviderConnect, Client Letter, ERCMS RADMD, Magellan, and Blue 2 to gather case data and document resolutions.
• Conduct thorough research, document pertinent details and actions, record outreach to business partners, and attach supporting documents to cases.
• Coordinate with internal business partners and obtain required data or medical records for cases involving clinical decisions, delegated vendors, claims, and network issues.
• Complete research and document supporting details to render final determinations, with verbal and/or written notification to appellants within required timeframes.
• Conduct outreach to members, providers, and internal and external business partners to resolve appeals and grievances.
• Facilitate escalated calls and issues from providers and members regarding appeals or dispute decisions; 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