Appeals & Grievance Coordinator

Job Description

Job Description

Imperial is seeking an Appeals and Grievances coordinator to help with the exchange side of Medical. Experienced and familiar with NCQA regulations.

Responsible for reviewing and resolving member complaints and appeals and communicating resolution to members in accordance with the standards and requirements established by Medicare and applicable state insurance regulations for the Exchange.

ESSENTIAL JOB FUNCTIONS:

1. Responsible for providing administrative support to ensure grievance and appeal cases are processed per regulatory guideline and internal department protocol including:
2. Coordinate, document and track all members, grievances and member and provider appeals and or grievances.
3. Generates written correspondence to members and providers and using appropriate grammar and punctuation.
4. Ensure all grievance and appeal communications are sent out within regulatory compliance guidelines.
5. Researches issues utilizing internal systems, outreach to providers, vendors and internal departments in order to fully respond to all issues raised in a grievance or to resolve appeal.
6. Requests medical records, clinical notes, and responses from providers, vendors and internal departments as needed.
7. Maintains working knowledge of regulatory guidelines surrounding grievances and appeals per Medicare and state regulations and per internal A & G policies & procedures.
8. Acts as a liaison between departments to coordinate information and close grievances and appeals within regulatory timelines.
9. Keeps A & G leadership aware of “open’ & “pending” grievance and appeal cases and expected resolution measures.
10. Adheres to payroll policies and properly uses timekeeping system with minimal manual changes.
11. Maintains regular and consistent attendance.

EDUCATION/EXPERIENCE:

• High school graduate or equivalent.
• 1 year of Medicare A&G experience required.
• Must have experience in making outgoing phone calls as well as taking incoming phone inquiries