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Appeal And Grievance Intake Coordinator

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Blue Cross Blue Shield of Arizona

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Location:
United States , Phoenix

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Category:
IT - Administration

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Contract Type:
Not provided

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Salary:

Not provided
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Job Description:

Performs triage (intake, classification, case file setup and assignment) of Medicare Part C and D grievances and appeals; provides administrative, clerical, and other related support to the Grievance and Appeals (G&A) staff; establishes, maintains, and monitors grievance and appeal workload tracking and workflow processes; assists with maintaining regulatory compliance, timeliness requirements and ensuring accuracy standards are met; completes day-to-day operational tasks assigned according to defined processes and procedures; prepares G&A case file folders and assists with tracking and maintaining G&A case records and files; and assists with collecting and reporting G&A related performance and regulatory data.

Job Responsibility:

  • Performs triage (intake, classification, case file setup and assignment) of Medicare Part C and D grievances and appeals
  • provides administrative, clerical, and other related support to the Grievance and Appeals (G&A) staff
  • establishes, maintains, and monitors grievance and appeal workload tracking and workflow processes
  • assists with maintaining regulatory compliance, timeliness requirements and ensuring accuracy standards are met
  • completes day-to-day operational tasks assigned according to defined processes and procedures
  • prepares G&A case file folders and assists with tracking and maintaining G&A case records and files
  • assists with collecting and reporting G&A related performance and regulatory data
  • Receive, sort, classify, prioritize, manage, and distribute inbound G&A mail, fax, inter-office, and other correspondence according to policies and procedures, the CMS Managed Care and Prescription Drug Benefit Manuals, and other regulatory and procedural rules, guidelines and timeframes
  • Prepare and assign individual case files to the appropriate G&A staff, continuously update tracking logs, databases, and reports, monitor and manage case status, timelines, statistics, regulatory compliance and performance as required
  • Prepare and mail, fax, inter-office, and other outbound correspondence
  • Coordinate with enrolled members and providers submitting grievances and appeals to obtain additional information or clarification as required
  • Coordinate case files with G&A Staff, Quality Management staff, Medical Directors and/or the Chief Medical Officer as required
  • Assist in the preparation and submission of cases to the Independent Review Entity (IRE), as required
  • Receive and coordinate Administrative Law Judge (ALJ), Medicare Appeals Council (MAC), and Federal District Court cases with the G&A staff, Medical Director, Legal, and other departments as required
  • Provide information regarding rights and responsibilities to enrolled members, providers, and other QHP departments as outlined in the Medicare Managed Care Manual

Requirements:

  • 2 years of experience in a Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) insurance plan and/or other managed care organization
  • High school diploma or GED in general field of study

Nice to have:

  • 2 years of additional experience, including working knowledge of CMS Managed Care Manual Chapter 13 - Beneficiary Grievances, Organization Determinations, and Appeals and CMS Prescription Drug Benefit Manual Chapter 18 - Part D Enrollee Grievances, Coverage Determinations, and Appeals
  • Knowledge of healthcare billing and claims adjudication processes

Additional Information:

Job Posted:
May 14, 2026

Employment Type:
Fulltime
Work Type:
Remote work
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