[Hiring] Appeals and Grievances Coordinator @Avesis

Role Description

The Appeals and Grievances Coordinator is the primary point of contact for members, providers, and clients throughout the appeals and grievances process. Although this role will report to the Supervisor, Appeals and Grievances, this individual will receive day-to-day performance support and case guidance from the A&G Team Lead. You will provide timely, accurate, and compliant resolution of dental and vision A&G cases within a regulated managed care environment. The coordinator collaborates with Claims, Provider Relations, Customer Service, and Clinical teams, and is expected to contribute to team onboarding and knowledge sharing as their experience grows.

• Responsible for the completion of appeals and grievances from all states
• Perform reviews of member and provider appeals and grievances for dental and vision waiver services
• Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions
• Document rationale clearly and accurately in alignment with organizational and regulatory standards
• Work closely with clinical teams as well as other internal operational areas to resolve complex cases
• Communicate outcomes effectively to members and providers
• Review and complete all provider appeals and grievances within required timeframes
• Review and complete member appeals and grievances within required timeframes
• Apply Avesis policy, plan documents and/or state guidelines when processing appeals or grievances
• Issue administrative denials appropriately
• Refer denials based on medical necessity to appropriate clinical staff
• Collaborate with appropriate stakeholders to prepare all requests for Independent External Review when required
• Participate in training programs to maintain functional expertise
• Perform any other job duties as requested

Qualifications

• High school diploma or equivalent
• 1+ years of exposure with medical, dental or vision terminology and/or coding (ICD-10, CDT, CPT)
• 1+ years of experience with case management platforms or healthcare administrative systems
• Working knowledge of medical, dental, or vision terminology and coding (ICD-10, CDT, CPT) relevant to the line of business
• Proficiency in Microsoft Office Suite and experience with case management platforms or healthcare administrative systems
• Ability to draft formal correspondence
• Demonstrated understanding of HIPAA and the ability to handle protected health information in a compliant manner
• Proven ability to manage a high-volume caseload, prioritize competing deadlines, and meet strict regulatory turnaround time requirements
• Strong attention to detail, critical thinking, and sound judgment with the ability to work both independently and collaboratively across departments
• Flexible to work alternating Saturday during holiday shifts as required
• Maintain internet service that allows you to complete your essential job duties without issue (50 Mbps download and 10 Mbps upload while hardwired and not on a VPN)

Requirements

• 1+ years of experience drafting adverse determination letters, supporting audit readiness, or working in managed care A&G case management platforms
• Familiarity with applicable federal and state regulations governing appeals and grievances, including 42 CFR Parts 422 and 438 and NCQA standards
• Registered Dental Hygienist or Dental Assistant credential

Benefits

• Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way
• Competitive compensation package
• Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period
• Life and disability insurance
• A great 401(k) with company match
• Tuition assistance, paid parental leave and backup family care
• Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent
• Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best
• Employee Resource Groups that advocate for inclusion and diversity in all that we do
• Social responsibility in all aspects of our work