Senior Coordinator , Complaint and Appeals - must reside in Ohio
About The Position
The Senior Coordinator, Complaint and Appeals prepares, researches, and evaluates information necessary to resolve member complaints, appeals, and grievances. The role reviews case documentation, analyzes benefit and policy information, and ensures accurate, timely, and compliant case resolution in accordance with established procedures and regulatory requirements. The Complaints & Appeals Analyst reviews, investigates, and resolves member complaints, appeals, and grievances. This role evaluates case information, researches complex issues, and communicates clear and accurate determinations. The analyst collaborates with internal business partners to resolve cases accurately and on time in accordance with applicable policies and procedures. The role requires residence in Ohio.
Requirements
- At least 5 years of work experience with Medicaid Complaint & Appeals.
- Strong analytical, problem-solving, and decision-making skills.
- Excellent written and verbal communication skills.
- Ability to manage multiple priorities and adhere to established deadlines.
- Proficiency in Microsoft Office applications.
- High school diploma or equivalent required.
- Must reside in Ohio.
Nice To Haves
- Experience in healthcare, insurance, claims, customer service, complaints and appeals, or related operations.
- Experience researching and resolving complex customer or member issues.
- Knowledge of health plan benefits, claims, and appeals processes.
Responsibilities
- Review and investigate member complaints, appeals, and grievances in accordance with established policies and procedures.
- Analyze case information, supporting documentation, and benefit information to determine appropriate case outcomes.
- Prepare accurate and timely written correspondence related to complaint and appeal determinations.
- Process cases within established quality, productivity, and turnaround-time standards.
- Research and resolve complex issues in collaboration with internal business partners and applicable stakeholders.
- Maintain accurate and complete case documentation in applicable systems.
- Identify potential trends or process concerns and escalate issues as appropriate.
- Participate in departmental projects, training, and process-improvement initiatives.
- Support compliance with federal and state regulations and internal policies governing complaint and appeal activities.
Benefits
- Medical coverage
- Dental coverage
- Vision coverage
- Paid time off
- Retirement savings options
- Wellness programs
- Other resources, based on eligibility
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
