Appeals & Grievance Specialist Coordinator

Position Title: Appeals & Grievance Specialist Coordinator
Work Arrangement: Remote Role
Assignment Duration: 4+ Months
Notes
Active, current, and unrestricted Registered Nurse (RN) license in the State of Arizona or a compact state is required.
Associate's Degree in a healthcare field of study or Nursing Diploma required.
Clinical - Must have RN license.

Position Summary:
Perform comprehensive clinical reviews and resolve provider appeals, member appeals, grievances, corrected claims, subscriber reconsiderations, and related inquiries across all lines of business. The role involves analyzing medical records, applying medical necessity criteria and benefit plan requirements, conducting claims research, interpreting policies and procedures, collaborating with internal and external stakeholders, and ensuring timely, accurate resolutions while meeting regulatory, accreditation, quality, and productivity standards.

Key Responsibilities:
Perform in-depth analysis, clinical review, and resolution of provider appeals, inquiries, corrected claims, subscriber reconsiderations, member appeals, and provider grievances across all lines of business.
Identify, research, process, resolve, and respond to customer inquiries through written and verbal communication.
Respond to a high volume of health insurance appeal-related correspondence.
Analyze medical records and apply medical necessity criteria and benefit plan requirements to determine the appropriateness of appeals, grievances, and reconsideration requests.
Maintain complete and accurate records in accordance with department policy.
Meet quality, quantity, productivity, accuracy, and timeliness standards required by department guidelines and regulatory agencies.
Apply plan policies and procedures effectively.
Consult and coordinate with internal departments, external health plans, providers, businesses, and government agencies to resolve customer inquiries.
Attend staff and interdepartmental meetings.
Participate in continuing education and remain current with developments in medicine and managed care.
Maintain compliance with State, Federal, and accreditation requirements.
Maintain productivity and accuracy goals in accordance with regulatory requirements, accreditation standards, and service level agreements.
Acquire specialized knowledge to complete Level 1 appeals, grievances, and corrected claims using benefit plan booklets, administrative guidelines, medical criteria, claims research, provider contracts, fee schedules, communication records, and precertification research.
Communicate benefit, eligibility, coverage, claims, programs, and provider network information to customers.
Deliver customer service aligned with the "Trusted Advisor" brand promise.

Qualification & Experience:
Level 1: Minimum 1 year of experience in a clinical, health insurance, or other healthcare-related field.
Associate's Degree in a healthcare field of study or Nursing Diploma.
Active, current, and unrestricted Registered Nurse (RN) license in the State of Arizona or a compact state.
Intermediate PC proficiency.
Intermediate proficiency using office equipment, including copiers, fax machines, scanners, and telephones.
Ability to maintain confidentiality and privacy.
Advanced clinical knowledge.
Strong interpersonal, active listening, and customer service skills.
Ability to compose business correspondence.
Ability to interpret and apply policies, procedures, programs, and guidelines.
Strong investigative, analytical, and research skills.
Ability to navigate, gather, input, and maintain records across multiple systems.
Ability to follow instructions and work independently with sound judgment.
Strong organizational, prioritization, and problem-solving skills.
Ability to establish and maintain collaborative working relationships.

Preferred Qualifications:
3 years of experience in a clinical, health insurance, or healthcare-related field.
Knowledge of Current CPT, ICD-9, ICD-10, HCPCS, and DRG coding.
Working knowledge of McKesson InterQual criteria and Medical Coverage Guidelines/Medical Policies.
Advanced ability to interpret contract language and benefit plans.
Bachelor's Degree in Nursing or a related healthcare field.