Appeal and Grievance Coordinator

• Responsible for intake, investigation and resolution of appeals, complaints and grievances scenarios for all products
• Ensure timely, customer focused response to appeals, complaints and grievance
• Identify trends and emerging issues and report and recommend solutions
• Research incoming electronic appeals, complaints and grievance to identify if appropriate for unit based upon published business responsibilities
• Research Standard Plan Design or Certification of Coverage relevant to the member to determine accuracy/appropriateness of benefit/administrative denial
• Research claim processing logic to verify accuracy of claim payment, member eligibility data, billing/payment status, prior to initiation of appeal process
• Identify and research all components within member or provider/practitioner appeals, complaints and grievance for all products and services
• Triage incomplete components of appeals, complaints and grievance to appropriate subject matter expert within another business unit(s) for resolution response content to be included in final resolution response
• Responsible for coordination of all components of appeals, complaints and grievance including final communication to member/provider for final resolution and closure
• Serve as a technical resource to colleagues regarding appeals, complaints and grievance issues, and similar situations requiring a higher level of expertise
• Identifies trends and emerging issues and reports on and gives input on potential solutions

• Experience in reading or researching benefit language
• 1-2 years experience that includes but is not limited too claim platforms, products, and benefits
• patient management
• product or contract drafting
• compliance and regulatory analysis
• special investigations
• provider relations
• customer service or audit experience

Experience in research and analysis of claim processing

• Affordable medical plan options
• 401(k) plan (including matching company contributions)
• employee stock purchase plan
• No-cost programs for all colleagues including wellness screenings, tobacco cessation and weight management programs, confidential counseling and financial coaching
• Benefit solutions that address the different needs and preferences of our colleagues including paid time off, flexible work schedules, family leave, dependent care resources, colleague assistance programs, tuition assistance, retiree medical access and many other benefits depending on eligibility