Grievance And Appeals Coordinator

TEKsystems•Los Angeles, CA

3d•$23 - $23•Remote

About The Position

The Grievances and Appeals Coordinator analyzes and resolves verbal and written claims, authorizations, complaints, grievances, and appeals from members and providers in a regulated healthcare environment. This role ensures timely, accurate, and compliant resolution of cases, supports performance and quality programs, and contributes to continuous improvement in member and provider experience through strong communication, documentation, and analytical skills.

Requirements

High school diploma or equivalent required; associate degree preferred.
2+ years of experience in appeals & grievances, claims, managed care, healthcare administration, or customer service.
Strong written and verbal communication skills.
Excellent attention to detail and accuracy.
Proficiency with digital tools, case management systems, and office software.
Strong analytical, research, troubleshooting, and problem-solving abilities.
Ability to manage high workloads and maintain organization in a fast-paced environment.
Comfortable working remotely and collaborating with cross-functional teams.
Commitment to quality, compliance, and maintaining high accuracy standards (97%+).

Nice To Haves

Associate’s degree in a related field is preferred.
Experience working with complex cases or compliance-related tasks in healthcare, insurance, or other regulated environments.
Knowledge of healthcare regulations, including health plan compliance and regulatory requirements, and familiarity with Medicare/Medicaid guidelines.
Conflict resolution skills, with the ability to handle sensitive cases with professionalism, empathy, and discretion.
Project coordination experience, including exposure to coordinating cross-functional projects or initiatives in a fast-paced environment.
Strong letter-writing skills, with the ability to tailor responses to members and providers while maintaining a professional tone.
Experience supporting pay-for-performance programs through data entry, tracking, and information research.
Experience with HEDIS-related functions such as data entry, provider outreach, and claims research.
Comfort working with performance metrics and quality indicators, including accuracy, timeliness, and customer satisfaction.
Demonstrated reliability and commitment to longer-term roles, with an interest in potential conversion from contract to permanent employment.

Responsibilities

Analyze and resolve verbal and written claims, authorization appeals, complaints, grievances, and appeals from members and providers.
Gather, analyze, and report data related to member and provider complaints, grievances, and appeals to support compliance and quality standards.
Prepare clear, professional response letters addressing member and provider complaints, grievances, and appeals.
Maintain accurate and organized files on individual appeals and grievances, ensuring proper documentation and record-keeping.
Coordinate the Grievance and Appeals Committee as needed, including preparing materials, organizing case reviews, and tracking outcomes.
Support pay-for-performance programs through data entry, tracking, organizing, and researching information related to performance metrics.
Assist with HEDIS production functions, including data entry, outbound calls to provider offices, and claims research to support quality reporting.
Manage high volumes of documents, including copying, faxing, and scanning incoming mail and case-related materials.
Research complex cases and compliance-related issues, ensuring decisions align with regulatory requirements and internal policies.
Collaborate proactively with management and cross-functional departments to resolve complex cases and improve processes.
Communicate clearly and professionally with internal teams, members, and providers regarding case status, outcomes, and next steps.
Meet or exceed established performance indicators, including accuracy, quality compliance, efficiency, productivity, and customer satisfaction.
Complete case reviews and resolutions within required timelines while maintaining high quality standards and attention to detail.
Contribute to continuous improvement initiatives by identifying trends, issues, and opportunities to enhance grievance and appeals handling.