Grievance and Appeals Coordinator

Process grievances and organization determinations, analyze, research, and provide comprehensive responses in accordance with established regulatory and accreditation guidelines. Contact customers to gather information and communicate disposition of case. Conduct pertinent research in order to evaluate, respond to, and finalize case. Familiar with standard concepts, practices, and procedures for analyzing, interpreting data and applying contract and regulatory provisions.

Analyze, research, resolve and respond to confidential/sensitive complaints, grievances and organization determinations from members, member’s representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.

Make grievance decisions and communicate decision to the claimant within regulatory and accreditation guidelines for timeliness, adhering to the strictest of timeframes for urgent and non-urgent requests, as imposed by the various federal and state laws.

Provide comprehensive grievances responses that support the decision and comply with regulatory and accreditation guidelines, and support the decision by referencing specific and applicable language from the plan documents, certificates, riders, and summary plan descriptions, or the internal rules, guidelines and protocols, as appropriate.

Analyze, research, resolve and respond to high level inquiries, referrals and complaints received from various regulatory agencies and other sources.

Maintain thorough knowledge of internal policies, procedures, regulations, charters for accurate resolution of complaints and grievances, including existing laws and regulations and new ones.

Remain up-to-date in the use of internal systems as well as vendor systems.

Perform other duties as requested.


• High School Diploma or GED required. Bachelor's Degree in Health Care Administration, English, Communications or related field preferred....