Member Appeals & Grievances Coordinator

Job Description

Job Description

Our client, a Medical Center company, is looking for a Member Appeals & Grievances Coordinator for their Charlestown, MA location.

• The Member Appeals and Grievances (A&G) Coordinator performs administrative functions associated with incoming Member Appeals and Grievances.
• The A&G Coordinator is responsible for identification, intake, and distribution of member appeals and grievances.
• The A&G Coordinator maintains organized, secure, and efficient record keeping processes.
• The A&G Coordinator is responsible for responding to other business areas and members / providers regarding status of appeals and grievances or A&G processes in a timely and professional manner.
• The A&G Coordinator establishes and maintains collaborative and meaningful interdepartmental relationships.
• The Member Appeals and Grievances (A&G) Coordinator performs administrative functions associated with incoming Member Appeals and Grievances.
• The A&G Coordinator is responsible for identification, intake, and distribution of member appeals and grievances.
• The A&G Coordinator maintains organized, secure, and efficient record keeping processes.
• The A&G Coordinator is responsible for responding to other business areas and members / providers regarding status of appeals and grievances or A&G processes in a timely and professional manner.
• The A&G Coordinator establishes and maintains collaborative and meaningful interdepartmental relationships.
• Appropriate and compliant identification of appeals and grievances during intake. Accurate and detailed entry into the A&G system of record.
• Timely distribution of all appeals and grievances to the Appeals and Grievances Specialists in accordance with department rules and deadlines.
• Responsible for data accuracy during entry into the A&G system of record to support the integrity of trend analysis and reporting and development/management of appropriate workflows to minimize manual errors and ensure compliance and consistency.
• Responsible for identifying trends and/or areas of concern to be raised to the A&G Management team.
• Assist the A&G Management team with audits and reporting needs as necessary and applicable.
• Participation / creation of daily, weekly and / or monthly reports for the A&G Management team as part of the internal auditing and monitoring program. Reports include analysis and trend identification.
• Participate in or lead training with the A&G Management team, A&G Specialists and / or new Coordinator staff.
• Includes maintenance of up-to-date materials related to the Coordinator role.
• Meets all required deadlines for entry into the A&G system of record, responses to inquiries from other departments, return telephone calls / voicemails, etc.
• Other appeals and grievances support duties as assigned.

• Bachelor’s degree in Health Care Administration, related field, or an equivalent combination of education, training, and experience is required.
• Microsoft Office Applications
• Demonstrated ability to use proprietary healthcare management system(s)
• Proven ability to identify problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
• Experience Preferred:
• JIVA
• Facets
• Express Scripts, Inc
• HPMS
• Access
• 2 or more years of experience in a healthcare setting, specifically related to Appeals and Grievances
• Experience with data entry, trend analysis, and reporting
• Experience with health insurance (Commercial, Medicaid and Medicare)
• Experience with rules and regulations governing health insurance (Commercial, Medicaid and Medicare)
• Experience communicating with a provider network
• Certified Professional Coder (CPC) certification
• Competencies, Skills, and Attributes:
• Excellent attention to detail and excellent organizational skills
• Excellent oral, written and interpersonal communication skills required
• Ability to be flexible and work independently, as well as collaborate with other departments across the organization
• Ability to work effectively in a fast paced environment
• Problem solving
• Ability to abstract data, analyze and identify trends
• Ability to multi task
• Ability to provide high quality customer service

• Health Benefits
• Referral Program
• Excellent growth and advancement opportunities