Appeal and Grievance Coordinator

SGS_JOB_1798

Information Technology
Remote
Appeals or Grievance and (Providers Appeals or Medicare) and (Customer Service or Call Center)

Contract - 06 Months (possible extension)

Outbound call experience (though not a large part of this job) is good to have. A customer service background and experience, not necessarily in the healthcare field, is a nice to have as well. Medicaid experience is desired and will make the candidate stand out. The job receives, researches and correctly classifies all grievance and appeals cases. This includes any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and state and federal regulations set forth for government products.

Job Responsibilities:

  • Appeal and Grievance Coordinator
  • Claims research and processing (more of researching why the claim was denied than actually researching into the claim)
  • Authorization lookup/ building authorizations as well as updating authorizations
  • Researching outside vendor sites for authorizations and review of notes
  • Reviewing appeal letters to determine what the provider is appealing
  • Responsible for starting the appeal process and researching the appeal. Responsible for sending out appeal determination letters and completing the appeal.
  • Extensive training on internal and external systems and the internal appeal process
  • Minimum education: At least a HS degree, but a college degree and/or extensive experience would be considered.

Skills:

  • Claims research and processing (more of researching why the claim was denied than actually researching into the claim)
  • Authorization lookup/ building authorizations as well as updating authorizations
  • Researching outside vendor sites for authorizations and review of notes
  • Reviewing appeal letters to determine what the provider is appealing
  • Responsible for starting the appeal process and researching the appeal. Responsible for sending out appeal determination letters and completing the appeal.
  • Extensive training on internal and external systems and the internal appeal process

Education/Experience:

  • Minimum education: HS Diploma

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