Appeals & Grievances Coordinator - Medicare/Commercial

Job Description

Job DescriptionAppeals & Grievances Coordinator - Medicare/Commercial

Join our client’s team as an Appeals & Grievances Coordinator and play a vital role in ensuring seamless resolution processes for member grievances and appeals within our innovative health plan. This remote opportunity offers you the chance to contribute to a reputable organization dedicated to providing exceptional service to Medicare and commercial members. With a focus on accuracy, efficiency, and customer satisfaction, your efforts will help uphold quality standards and compliance across all appeals and grievances activities.

Compensation: $25/hour

Responsibilities:

• Manage a high volume of incoming grievances and appeals from initiation to resolution, consistently meeting contractual and internal deadlines.
• Maintain detailed and precise documentation for all appeals and grievances within designated tracking systems, ensuring comprehensive records.
• Oversee the completeness and accuracy of case files, including research materials, acknowledgment and resolution letters, and relevant documentation.
• Collaborate effectively with internal teams such as Compliance, Pharmacy, Medical Directors, and Sales, as well as external agencies, to facilitate case resolutions.
• Prepare documentation and files for external reviews and hearings, ensuring adherence to regulatory standards.
• Independently engage with members regarding their appeals—whether administrative, clinical, or pharmacy—to provide ongoing updates and resolve concerns.
• Support provider interactions by resolving payment issues, claims processing concerns, and identifying system improvement opportunities to reduce future appeals.
• Contribute to the preparation of reports and data analysis related to member and provider appeals and grievances, offering insights for process enhancements.
• Stay informed on the latest updates to health plan policies, regulations, and contractual obligations, applying knowledge to all case work.
• Participate actively in team meetings, audit processes, and continuous improvement initiatives, contributing to an inclusive, collaborative work environment.
• Exhibit flexibility by providing on-call coverage during weekends and holidays to meet organizational needs.
• Uphold a culture of diversity, equity, and inclusion, fostering positive relationships across all stakeholders.

Requirements:

• Bachelor’s degree or an equivalent mix of training and professional experience, supported by 3-5 years of relevant health plan industry experience.
• Demonstrated expertise in managing appeals and grievances in Medicare and Medicaid plans, with a preference for experience in Medicare Advantage.
• Strong organizational skills with the ability to manage multiple cases efficiently without becoming flustered.
• Exceptional verbal and written communication abilities.
• Solid understanding of health plan operations coupled with proficiency in Microsoft Excel and Word.
• Capable of handling sensitive, confidential information with professionalism.
• Familiarity with healthcare regulations, policies, and contractual obligations.
• Bilingual skills are a plus.

Our Commitment to Inclusion & Belonging
The Hollister Group is an equal opportunity employer. We welcome and encourage applications from people who are under-represented in their respective occupation or position.

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#LI-KM1Pandologic. Keywords: Grievance and Appeals Coordinator, Location: Somerville, MA - 02145 , PL: 602467434