Appeals and Grievance Coord II

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Doral, Florida, 33166, United States
Make a meaningful impact with every interaction. As an Appeals and Grievance Coordinator, you’ll research and help resolve complex issues related to callers’ healthcare, account status, and potential plan options. You’ll manage enrollment and billing activities, maintain assigned accounts, and navigate multiple databases to find the information needed to support each caller. This role is ideal for someone who is tech-savvy, detail-oriented, and confident communicating with compassion while managing multiple systems at once.

ESSENTIAL DUTIES AND RESPONSIBILITIES

  1. Coordinates the intake of appeal and grievances requests from members and providers into the designated systems.
  2. Generates Acknowledgement Letters to mail to appellants and answering general appeal status questions.
  3. Compiles case files to be sent to Independent Review Entity (IRE).
  4. Ensures adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required timeframes.
  5. Prepares case files for Independent Review Entities or other escalated types of cases, including documentation of the Statement of Position and case narratives.
  6. Develops Grievance and Appeal request information from designated databases.
  7. Assists Investigation and Appeals Specialists with appeal and grievance resolutions.
  8. Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner
  9. Demonstrates courtesy and politeness to patients, visitors, callers and other employees.

EDUCATION

Bachelor’s degree in business or related field.

WORK EXPERIENCE

Two (2) years’ experience working in a managed care environment in grievance or appeals, claims or related experience. Or Equivalent Combination of Training and Experience

LANGUAGE SKILLS

Bilingual English/Spanish fluency.

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