Appeal & Grievance Intake Coordinator

• 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

• 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
• Math, communications and business skills normally demonstrated by a high school degree or equivalent
• Intermediate PC user, including Microsoft Word, Excel, Outlook, Power Point, and Adobe Acrobat Pro
• Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones
• Maintain confidentiality and privacy as outlined by HIPAA
• Strong critical thinking skills
• Must possess highly developed interpersonal skills and communications skills, with a strong customer service orientation, and practice interpersonal and active listening skills to achieve customer satisfaction
• Compose a variety of business correspondence
• Interpret and translate policies, procedures, programs and guidelines
• Strong investigative and analytical research skills
• Navigate, gather, input and maintain data records in multiple system applications
• Follow and accept instruction and direction
• Establish and maintain working relationships in a collaborative team environment
• Organizational skills with the ability to prioritize tasks and work with multiple priorities

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