Quality Improvement Coordinator (QIC) - Grievances Remote Nationwide
About The Position
The Quality Improvement Coordinator (QIC) - Grievances is responsible for reviewing, researching, and resolving member grievances in accordance with regulatory, contractual, and organizational requirements. This role manages cases from intake through resolution, ensuring accuracy, timeliness, and high-quality documentation. The Coordinator collaborates with internal departments, health plans, and providers to gather information and support appropriate determinations. This position operates under the direction and oversight of the Quality Operations Manager and/or designated leadership, following established workflows and procedures.
Requirements
- High School Diploma/GED
- 2+ years of experience working with appeals and grievances in healthcare
- 2+ years of experience with medical terminology
- Intermediate level of proficiency with MS Office
Nice To Haves
- Minimum 1–3 years of experience in grievance, appeals, quality, or clinical operations
- Experience using referral management systems, electronic health records, or claims platforms
- Strong working knowledge of CMS, DMHC, NCQA, or other regulatory requirements related to grievances and appeals
- Ability to manage multiple cases, meet deadlines, and work independently in a fast-paced environment
- Excellent written and verbal communication skills, with the ability to draft clear and compliant member correspondence
Responsibilities
- Review, research & analyze grievance information
- Receive and analyze grievance documentation to determine relevant details
- Review and reconsider determinations regarding reopened cases when appropriate
- Make outbound calls to health plans and/or providers for clarification
- Identify whether additional clinical or administrative reviews are needed. Obtain and review medical records for additional review levels
- Work collaboratively with claims, UM, provider groups, and other departments
- Support grievance audits and respond to regulatory or plan inquiries
- Manage all aspects of the grievance case process from intake to resolution
- Utilize systems to track, document & communicate case progress
- Research case information across multiple internal systems
- Maintain complete and accurate documentation in grievance tracking systems
- Draft and send grievance acknowledgement, status, and outcome letters
- Edit documents for accuracy, clarity, and reading level
- Maintain confidentiality in accordance with HIPAA and internal guidelines
- Upload required documentation and ensure all records are complete prior to case closure
- Respond to escalated issues and represent the department professionally
- Communicate grievance status and outcomes professionally to internal and external stakeholders
- Respond to questions or follow-up requests related to assigned cases
- Escalate complex issues to leadership per established procedures
Benefits
- comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
High school or GED
