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Commercial and Government Benefits
Appeals and Grievances Coordinator
Location
United States
Posted
23 days ago
Salary
$18.3K - $30.6K / year
Seniority
Junior
Job Description
Appeals and Grievances Coordinator
Avēsis
• The Appeals and Grievances Coordinator is the primary point of contact for members, providers, and clients throughout the appeals and grievances process. • Provide timely, accurate, and compliant resolution of dental and vision A&G cases within a regulated managed care environment. • Responsible for the completion of appeals and grievances from all states. • Perform reviews of member and provider appeals and grievances for dental and vision waiver services. • Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions. • Document rationale clearly and accurately in alignment with organizational and regulatory standards. • Work closely with clinical teams as well as other internal operational areas to resolve complex cases. • Communicate outcomes effectively to members and providers. • Review and complete all provider appeals and grievances within required timeframes. • Review and complete member appeals and grievances within required timeframes. • Apply Avesis policy, plan documents and/or state guidelines when processing appeals or grievances. • Issue administrative denials appropriately. • Refer denials based on medical necessity to appropriate clinical staff. • Collaborate with appropriate stakeholders to prepare all requests for Independent External Review when required. • Participate in training programs to maintain functional expertise. • Draft formal correspondence such as acknowledgement and resolution notices.
Job Requirements
- High school diploma or equivalent.
- 1+ years of exposure with medical, dental or vision terminology and/or coding (ICD-10, CDT, CPT).
- 1+ years of experience with case management platforms or healthcare administrative systems
- Working knowledge of medical, dental, or vision terminology and coding (ICD-10, CDT, CPT) relevant to the line of business.
- Proficiency in Microsoft Office Suite and experience with case management platforms or healthcare administrative systems.
- Ability to draft formal correspondence.
- Demonstrated understanding of HIPAA and the ability to handle protected health information in a compliant manner.
- Proven ability to manage a high-volume caseload, prioritize competing deadlines, and meet strict regulatory turnaround time requirements.
- Strong attention to detail, critical thinking, and sound judgment with the ability to work both independently and collaboratively across departments.
- Flexible to work alternating Saturday during holiday shifts as required.
Benefits
- Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
- Life and disability insurance.
- A great 401(k) with company match.
- Tuition assistance, paid parental leave and backup family care.
- Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
- Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
- Employee Resource Groups that advocate for inclusion and diversity in all that we do.
- Social responsibility in all aspects of our work.
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