Senior Coordinator, Grievance & Appeals

Overview

Performs triage tasks, including intake, classification, setup, and assignment of grievances and appeals. Additionally, provides administrative support to staff, including tasks such as clinical case file preparation for appeals. This includes retrieving documents from related systems (such as case notes, Initial adverse determinations, medical records/letters, appointed representative information, Uniform Assessment System evaluations, tasking tools, etc.), issuing correspondence like appointment of representative requests, medical record requests, acknowledgment, and decision notices, and making necessary updates to relevant systems as required.

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. Assists with collecting, tracking, and reporting data. Works under general supervision.

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 30 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

• Identifies case types (e.g.
  
  - clinical vs non-clinical appeals) during the intake process, communicates and responds to department inquiries such as case status. Initiates follow up emails when additional information is required.
• Identifies the clinical appeal documentation needed for review by the G&A RNs by preparing cases and ensuring all pertinent information is included in the case file. Conducts preliminary review to determine the case level and type and records the findings in the case. Uploads and document information into the tracking database, identifying key information. Assigns cases according to established departmental processes.
• Assists with triaging cases for valid appeals and moving out of triage accordingly. Tracks the chain of custody of case records in and out of the department, according to established procedures. Maintains confidentiality of information.
• Maintains knowledge of Grievance and Appeals (G&A) procedures, and CMS and DOH regulatory requirements and time frames applicable to the role, and prioritizes work accordingly.
• Assists with identifying, entering/updating missing data fields from the various systems that are necessary for the G&A database, including providing follow-up support to the RNs such as obtaining Initial Adverse Determinations notices.
• Prepares cases sent for external reviews in accordance with established procedures. Assists with entering the case into the G&A tracking system, tracks receipt, ensures that the reply is reviewed by the staff and implements action as appropriate.
• Prepares and issues template letters, including but not limited to acknowledgment letters, extension notices and clinical appeal decision letters. Prepares letters requesting Appointment of Representative (AOR) forms in grievances and appeals filed on behalf of the member's representatives. Prepares letters requesting Waiver of Liability (WOL) forms in appeals filed by non-participating providers. Follows up with the members and the providers via telephone and mail to request timely access to WOL and AOR forms as needed.
• Assists with updating of authorization related to overturned and partially overturned casesli>
• Collaborates with the clinical team to ensure appropriate notices and follow- ups are completed and the third- party administrator staff to facilitate appropriate case files and updates are sent. Also collaborates with internal department staff to address inquiries, check case status, or requesting additional information.
• Recommends improvements in the effectiveness or efficiency of workflows for improved departmental operations and timely…