Grievances & Appeals Coordinator

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. For more information, visit AmHealthPlans.com.

If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application!

Benefits and Perks include:

• Affordable Medical/Dental/Vision insurance options
• Generous paid time-off program and paid holidays for full time staff
• TeleDoc 24/7/365 access to doctors
• Optional short- and long-term disability plans
• Employee Assistance Plan (EAP)
• 401K retirement accounts with company match
• Employee Referral Bonus Program

Position Summary:

The Appeals and Grievances Coordinator is responsible for the timely and accurate intake, research, documentation, processing, tracking, and resolution of Medicare Advantage appeals and grievances. The Coordinator manages multiple priorities in a deadline-driven environment while maintaining accurate records, protecting confidential information, and meeting applicable federal, state, accreditation, contractual, and organizational requirements for their caseload.

Essential Functions: To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation.

• Receive and review appeals, grievances, complaints, and related correspondence submitted by mail, fax, or internal service request and log in the appropriate tracking system or log, correctly categorizing requests and identifying and removing duplicates.
• Receive and review incoming documentation to identify relevant information and route accordingly.
• Communicate and collaborate with multiple departments to ensure accurate and timely completion of appeals, grievances, and complaints, including Utilization Management, Claims, Compliance, or any other operational area as required.
• Ensure appropriate resolution of inquiries, grievances, and appeals within timeframes established by regulatory or accreditation agencies and organizational requirements.
• Prepare accurate, complete, and professional correspondence following CMS guidelines for required communications related to appeals, grievances, complaints, and other reconsideration requests as needed.
• Maintain complete and accurate electronic case records, logs, supporting documentation, correspondence, research, decisions, actions, and evidence of distribution in accordance with applicable requirements.
• Maintain and monitor assigned caseload from intake to resolution.
• Escalate issues appropriately and work with other departments to resolve member or provider concerns.
• Identify and report recurring issues, root causes, trends, processing barriers, compliance concerns, and areas of opportunity to leadership.
• Ensure all relevant CMS, HIPAA, local, state, and federal requirements are followed and identify any risks that may place the assigned caseload out of compliance.
• Work cooperatively with team members to manage assigned and shared workloads, participate in training and process discussions, and provide workload coverage when needed.
• Perform other related duties as assigned.

Required Skills:

• Excellent written and verbal communication skills and active listening.
• Positive and professional customer service skills.
• Strong research, analytical thinking, critical thinking, and problem-solving skills.
• Strong attention to detail and commitment to complete, accurate documentation.
• Ability to manage multiple cases, competing priorities, and critical deadlines while working independently; interpret and apply policies, procedures, regulatory guidance, and case-specific information; and recognize when escalation is required.
• Ability to perform in potentially stressful situations, including state, federal, NCQA, URAC, or other regulatory or accreditation audits.

Required Work Experience:

• Two or more years of experience in health insurance, managed care, claims, utilization management, appeals and grievances, compliance, or comparable healthcare operations preferred. An equivalent combination of education and relevant experience may be considered.
• Medicare or Medicare Advantage appeals and grievances experience preferred.
• Experience reviewing claim denials, authorization-related issues, provider disputes, or member and provider correspondence preferred.
• Experience working with physicians, clinicians, providers, or health plan operational departments preferred.
• Knowledge of complaint and appeal procedures, managed care, utilization management, and applicable CMS or accreditation requirements preferred.
• Customer service experience.
• Proven ability to problem-solve and make well-researched decisions.
• No disqualifying criminal background.

Licensing/Certification/Education Requirements:

• High school diploma required.
• Associate degree preferred.
• Successfully completed college courses in a relevant field to compensate for experience preferred.
• Medicare experience preferred.

Other Requirements:

• Position may require unscheduled overtime or weekend work.
• Must be willing and able to work flexible hours.
• Travel required.

Required Computer Software/Equipment Used:

• Microsoft Outlook, Word, and Excel.
• Ability to learn and use claims, case-management, document-management, fax, tracking, HRIS, and scheduling systems as applicable.
• Standard office equipment and computer.

Physical Requirements:

• Allows for standing, walking, and sitting.
• Work is generally performed in a standard office or approved remote-work environment and requires extensive computer use, document review, written communication, and telephone or electronic coordination.
• The physical demands described here are representative of those required to perform the essential functions of the position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Required Safety Expectations:

• Work safely and follow safety rules.
• Report unsafe working conditions and behaviors.
• Take reasonable and prudent actions to prevent others from engaging in unsafe practices.

Supervisory Responsibilities:

• This position does not have direct supervisory responsibilities.
• Supervisor frequently determines priorities.
• The employee manages assigned work independently and seeks leadership direction for unclear, complex, or extraordinary circumstances.

COMPETENCIES:

Analytical Thinking: Able to gather and analyze data and reach appropriate conclusions; solves problems in a timely manner.

Customer Service: Possesses good interpersonal skills while dealing with emotional or difficult situations; responds promptly to customer needs.

Accountability: Accepts responsibility for own decisions, actions, and results; able to maintain dependable behavior in times of crisis or complexity.

Attendance: Is consistently at work and on time; ensures work responsibilities are covered; arrives at meetings on time; returns from lunch and breaks appropriately.

Communication: Speaks and writes clearly and persuasively; listens and gets clarification.

Ethical Behavior: Upholds organizational values and abides by state and federal regulations; maintains confidentiality of HIPAA information; treats others with respect.

Initiative: Seeks increased responsibility; sets self-improvement goals linked to organizational goals.

Job and Industry Knowledge: Demonstrates knowledge of the position and industry; seeks additional information.

Productivity and Quality of Work: Maintains a high level of performance while demonstrating commitment to accuracy and thoroughness.

Teamwork: Displays ease working with others; contributes ideas and skills to the team; puts team success above own interests.