Coordinator, Appeals & Grievances

Evolent

5d • Remote

About The Position

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture. The Coordinator, Appeals and Grievances at Evolent will serve as a point of contact for processing post determination reviews and appeals requests in accordance with departmental policies, regulatory requirements, and client contractual agreements. Schedule: 10:30 am to 7 pm CST The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of a highly trained dedicated team focusing on appeals and post-determination requests. Coordinators collaborate daily with their peers, senior coordinators and managers, as well as clinicians and other internal departments when needed. This teamwork approach ensures consistent communication, knowledge sharing and support across the department, helping coordinators succeed in their roles. Our team values collaboration, continuous learning, and a member-centric approach, ensuring that every team member contributes to providing better health outcomes for our members and the health plans we serve.

Requirements

• A high school diploma or GED. (Required)
• 3 years of experience in an Intake Coordinator role or other relevant experience gained through roles with a health plan, managed care organization or third-party administrator. (Required)
• Ability to read, write and speak the English language fluently with patients and providers. (Required)
• Ability to adapt to fluctuating situations and perform work of a detailed nature, while avoiding errors. (Required)
• Proficient using computer and Windows PC applications, which includes strong keyboard and navigation skills. (Required)
• We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router.
• All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment.

Nice To Haves

• 2 years of experience processing appeals. (Preferred)
• Demonstrated ability meeting established goals while balancing a workload and prioritizing assignments in a remote environment. (Preferred)

Responsibilities

• Review and process appeal requests received via phone inbound, fax, or email in accordance with regulatory requirements and health plan guidelines.
• Outbound calls for follow-up as needed.
• Conduct research and analysis of case documentation, claims data, and medical records to ensure case files are complete.
• Contacts providers when additional information is needed.
• Manage workload effectively by moving cases through the appropriate stages timely to ensure service level agreements are met.
• Maintain accurate documentation and tracking in internal systems to support the appeal workflow, reporting, and compliance.
• Generate and/or verify the submission of acknowledgement letters for delegated appeals in accordance with regulatory standards.
• Meet established department guidelines related to productivity, quality and timeliness.

Benefits

• As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees.

What This Job Offers

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