This job is closed
We regret to inform you that the job you were interested in has been closed. Although this specific position is no longer available, we encourage you to continue exploring other opportunities on our job board.
Leon Health - Miami, FL
posted 2 months ago
About the position
The Grievance and Appeals Coordinator at Leon Health is responsible for analyzing and resolving grievances and appeals related to Medicare managed care. This role involves direct communication with members and providers, ensuring compliance with federal and state regulations, and maintaining accurate records within the organization's system. The coordinator will also prepare cases for medical review and serve as a liaison between various stakeholders to facilitate effective resolution of issues.
Responsibilities
- Analyze and resolve verbal and written claims, medical pre-service appeals, and Part D pre-service appeals from both providers and members.
- Intake verbal grievance and appeals requests from Member Services and migrate them to the Appeals & Grievance system for tracking and processing.
- Resolve all state inquiries related to complaints, grievances, and appeals.
- Adhere to all federal, state, and organizational regulations and policies pertinent to the review and processing of grievances and appeals.
- Prepare cases for medical review as necessary.
- Review grievances to identify potential quality or access issues and escalate for clinical review.
- Draft and mail all provider and member grievance and appeals-related communications within required timeframes.
- Conduct outreach to members and providers for additional information required to resolve cases.
- Provide members and/or providers with status updates regarding their open grievances or appeals.
- Collaborate with subject matter experts to obtain benefit and/or clinical opinions on complex cases.
- Serve as a liaison between members, providers, regulatory agencies, and internal staff.
- Correspond with key individuals regarding grievance and appeal decisions.
- Act as a subject matter expert regarding grievances and appeals.
Requirements
- Excellent written and oral communication skills.
- Ability to multi-task accurately and efficiently.
- Maintain production and accuracy standards.
- Strong analytical skills.
- Associate's degree in a related field or equivalent experience.
- 2 years of claims, contracting, or related experience in a managed care environment (preferably Medicare Advantage).
Benefits
- Full-time position with competitive salary range of $47.9K - $60.6K per year.
