Job Description

Title:  Appeal & Grievance Coordinator
Location:  Remote

Receive, investigate and triage expedited appeal requests received from members/member and provider representatives enrolled in Senior Products. Timely assignment of cases is critical to ensure member's and/or provider's appeal rights are processed in accordance with regulatory agencies' standards, including the Center for Medicare and Medicaid Services (CMS) and National Committee for Quality Assurance (NCQA).

Responsibilities:

• Claims research and processing (more of researching why the claim was denied than actually researching into the claim)
• Authorization lookup/ building authorizations as well as updating authorizations
• Researching outside vendor sites for authorizations and review of notes 
• Reviewing appeal letters to determine what the provider is appealing 
• Responsible for starting the appeal process and researching the appeal.
• Responsible for sending out appeal determination letters and completing the appeal.
• Extensive training on internal and external systems and the internal appeal process

Requirements:

• At least 1 year of experience in health insurance claims and appeals is strongly preferred.
• At least a HS degree, but a college degree and/or extensive experience would be considered.
• Outbound call experience (though not a large part of this job) is a good to have.
• A customer service background and experience, not necessarily in the healthcare field, is a nice to have as well.
• Medicaid experience desired and will make the candidate stand out.