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Appeals & Grievances Coordinator

Orange, CA · Healthcare
Appeals & Grievances Coordinator – Managed Care
Orange, CA
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 5-6 months, or longer! ***
Appeals & Grievances Coordinator Job Summary:
  • Screens and prioritizes incoming denials, appeals, and grievances.
  • Supports clinical staff (nurses, physicians, etc) involved in the denials, appeals, and grievances process.
  • Processes incoming requests, including forwarding case files and supporting documentation, based on established guidelines.
  • Forwards denials, appeals, and grievances requests that require clinical judgment to department Nurses, the Manager, or Medical Director.
  • Maintains a full caseload while meeting or exceeding designated metrics and turn-around timeframes.
  • Answers inbound calls from providers and other departments, verifies status of all denials, appeals, and grievances, and enters the information necessary to complete the caller’s request into the designated database.
  • Informs providers of the decision on their requests, per department procedure.
  • Assists with the resolution of escalated member or provider inquiries related to denials, appeals, and grievances.
  • Serves as subject matter expert for members, providers, and internal departments to promote an understanding of the denial, appeal, and grievance requirements and processes.
Appeals & Grievances Coordinator Background:
  • Requires an education level of at least an Associate’s or Bachelor’s degree; additional years of experience will be considered.
  • Requires exceptional phone / customer service skills, as well as very strong computer user skills.
  • At least 2-3 years’ experience in a medical office, hospital or health plan call center, or other healthcare support role with heavy computer & phone use.
  • Requires 2-3 years of claims, contracting, or related experience, at a Managed Care Organization (Health Plan, IPA/Medical Group, HMO, TPA/MSO, etc).
  • Prefer around 1-2 years of direct experience handling Denials & Grievances & Appeals.
  • Requires basic to intermediary familiarity with Medical terminology (1-3 years direct experience).
  • Direct experience with guidelines for Medicaid/Medicare and related state programs is required.
  • Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
  • Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
  • Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
Lean Bordador
Search Consultant
480-691-2307 (CALL – TEXT – FAX)
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