Morgan Stephens
Job Description: Appeals and Grievances Coordinator
Job Summary
The Appeals and Grievances Coordinator is responsible for reviewing and resolving member and provider complaints and communicating resolutions to members and providers (or authorized representatives) in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS). This position requires dependability, good grammar skills, and strong phone communication skills.
Day-to-Day Responsibilities
Research and respond to Medicare grievances in accordance with CMS regulations (training will be provided).
Conduct comprehensive research and resolution of appeals, disputes, grievances, and/or complaints from Managed Care Organization members, providers, and related outside agencies to ensure internal and regulatory timelines are met.
Research claims appeals and grievances using support systems to determine appeal and grievance outcomes.
Request and review medical records, notes, and/or detailed bills as appropriate; formulate conclusions per protocol and other business partners to determine responses; ensure timeliness and appropriateness of responses per state, federal, and Managed Care Organization guidelines.
Meet production standards set by the department.
Apply contract language, benefits, and review covered services.
Contact members/providers through written and verbal communication.
Prepare appeal summaries, correspondence, and document findings. Include information on trends if requested.
Compose all correspondence and appeal/dispute and/or grievances information concisely and accurately, in accordance with regulatory requirements.
Research claims processing guidelines, provider contracts, fee schedules, and system configurations to determine the root cause of payment errors.
Resolve and prepare written responses to incoming provider reconsideration requests relating to claims payments and requests for claim adjustments or from outside agencies.
Knowledge/Skills/Abilities
Dependability and strong organizational skills.
Excellent grammar and verbal communication skills.
Ability to work independently and manage time effectively.
Strong analytical and problem-solving skills.
Proficient in Microsoft Office, especially Excel.
Healthcare background preferred.
Familiarity with Medicaid and Medicare claims denials and appeals processing.
Knowledge of regulatory guidelines for appeals and denials.
Ability to meet deadlines and production standards.
Required Education
High School Diploma or equivalency
Required Experience
Minimum of 2 years of operational managed care experience (call center, appeals, or claims environment).
Health claims processing background, including coordination of benefits, subrogation, and eligibility criteria.
Strong verbal and written communication skills.
Position: Appeals and Grievances Coordinator
Pay Rate: $20/hr
Location: 100% Remote (Prefer candidates in MT/PT zones, others can be in CT and ET)
Schedule: 8:00 AM to 5:00 PM in their time zone
Benefits: Various levels of benefit plans available, including health, dental, and vision, offered by the agency at an additional cost. Temp-to-perm opportunity after 13 weeks.
Morgan Stephens
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