Grievance & Appeals Coordinator

Job Summary

Analyzing and resolving grievances and appeals, the full-time remote Grievance & Appeals Coordinator II will handle member and provider complaints while ensuring compliance with federal, state, and organizational regulations.

Key responsibilities

• Review and process grievances and appeals from members and providers according to established guidelines
• Collaborate with internal teams and subject matter experts to prepare cases for medical review and determine outcomes
• Serve as a liaison between members, providers, and regulatory agencies, communicating decisions effectively

Required qualifications

• Bachelor's degree in a related field or equivalent experience
• 2+ years of experience in claims, contracting, or a related role within a managed care environment
• Experience in investigating and resolving complaints and grievances
• Strong understanding of federal and state regulations related to grievances and appeals
• Ability to lead and participate in Appeals and Grievance Committees