Coordinator, Appeals and Grievances

$41,600 - $47,840/Yr

Evolent Health - Juneau, AK

Full-time

Juneau, AK

Professional, Scientific, and Technical Services

About the position

The Grievance and Appeals Coordinator at Evolent Health plays a crucial role in managing and resolving member and provider appeals and grievances. This position involves receiving, investigating, and ensuring compliance with regulatory standards while collaborating with a team to maintain service level agreements for various clients. The role emphasizes the importance of effective communication and organizational skills to facilitate the appeals process efficiently.

Responsibilities

• Receive faxes, emails, and mail to initiate an appeal or grievance request utilizing multiple software applications.
• Make outbound calls when necessary to obtain additional information pertaining to the research of an appeal or grievance.
• Triage & assign cases amongst the team on a rotating basis.
• Collect, organize, and track information received from a variety of resources to facilitate and expedite the processing of appeals and grievances.
• Generate acknowledgement letters for member appeals and grievances in accordance with regulatory standards.
• Initiate, research, and resolve member grievances in accordance with company and regulatory standards.
• Initiate, research, and refer member appeals to the Appeals RN.
• Initiate, research, and resolve provider appeals or refer to the Appeals RN, as necessary.
• Generate resolution letters, as appropriate.
• Utilize multiple internal and external computer applications and programs.
• Meet established productivity and quality standards.
• Provide rotating holiday coverage to intake emergent/urgent cases.
• Act as a backup coordinator.
• Perform other duties as assigned.

Requirements

• 3 years of experience minimum in processing appeals and grievances - Required
• 3 years of experience within a health plan, managed care organization or third-party administrator - Required
• Understanding of appeals process and utilization management - Required
• Excellent verbal and written communication skills - Required

Nice-to-haves

• Working knowledge of regulatory and accreditation requirements - Preferred
• Experience in Medicaid with knowledge of NCQA guidance/regulations for appeal and grievance processing - Preferred

Benefits

• Comprehensive health insurance benefits
• Bonus component based on pre-defined performance factors