Temporary Coordinator remote - Appeals & Grievances - MediGold Health Plan
Trinity Health, Columbus, OH, United States
Overview
This is a temporary, full‑time position with an expected duration to July 2026. The role requires full-time work Monday through Friday during the day shift.
Position Purpose
The Appeals and Grievance Coordinator is responsible for the processing and resolution of appeals, grievances and disputes from members and providers.
What You Will Do
Document all appeal requests or grievances upon receipt in the operating systems and route cases to appropriate clinical personnel for review.
Obtain confidential medical records from provider offices using secure methods.
Prepare case files and review with clinical colleagues.
Screen all incoming grievances, appeals and provider claim disputes to ensure compliance with CMS guidelines and corporate policies.
Gather, analyze and report verbal and written member and provider complaints, grievances and appeals in accordance with Federal regulations and time constraints.
Conduct investigations through internal and external interviews, chart and contract audits, inspections, and interpretation of CMS guidance and policies.
Prepare background, case summary and case files with records for submission to the Independent Review Entity (IRE) and ensure compliance and required timeframes are met.
Obtain required documents and fully prepare cases for Appeals Committee (MAC) review, Administrative Law Judge (ALJ) hearings.
Prepare and review data universes for CMS audits.
Participate in regular monitoring efforts and report trending and outliers to senior management.
Ensure 5-Star (maximum) ratings for CMS appeals and grievance related measures to support payment methodology and reimbursement.
Maintain compliance with all regulatory requirements for beneficiary protection areas of appeals and grievance.
Perform additional duties as assigned.
Minimum Qualifications
Education: Bachelor’s degree or equivalent combination of education and experience.
Experience: Three years of customer service or appeals and grievance experience, preferably in managed care or another health care setting.
Legal or regulatory background or experience highly desired.
Strong written and verbal communication skills; public speaking/educator experience desired.
Ability to interpret and apply Federal law and regulatory requirements ensuring compliance with Medicare Managed care obligations.
Ability to educate staff, providers, and enrollees about the appeals and grievance process.
Familiarity with claims processing, coordination of benefits, and use of claims processing system.
Ability to follow Federal guidelines from CMS and Ohio Department of Insurance (ODI) for appeal and grievance resolution processes and requirements.
Equal Opportunity Statement
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, or basis of disability or any other federal, state, or local protected class.
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This is a temporary, full‑time position with an expected duration to July 2026. The role requires full-time work Monday through Friday during the day shift.
Position Purpose
The Appeals and Grievance Coordinator is responsible for the processing and resolution of appeals, grievances and disputes from members and providers.
What You Will Do
Document all appeal requests or grievances upon receipt in the operating systems and route cases to appropriate clinical personnel for review.
Obtain confidential medical records from provider offices using secure methods.
Prepare case files and review with clinical colleagues.
Screen all incoming grievances, appeals and provider claim disputes to ensure compliance with CMS guidelines and corporate policies.
Gather, analyze and report verbal and written member and provider complaints, grievances and appeals in accordance with Federal regulations and time constraints.
Conduct investigations through internal and external interviews, chart and contract audits, inspections, and interpretation of CMS guidance and policies.
Prepare background, case summary and case files with records for submission to the Independent Review Entity (IRE) and ensure compliance and required timeframes are met.
Obtain required documents and fully prepare cases for Appeals Committee (MAC) review, Administrative Law Judge (ALJ) hearings.
Prepare and review data universes for CMS audits.
Participate in regular monitoring efforts and report trending and outliers to senior management.
Ensure 5-Star (maximum) ratings for CMS appeals and grievance related measures to support payment methodology and reimbursement.
Maintain compliance with all regulatory requirements for beneficiary protection areas of appeals and grievance.
Perform additional duties as assigned.
Minimum Qualifications
Education: Bachelor’s degree or equivalent combination of education and experience.
Experience: Three years of customer service or appeals and grievance experience, preferably in managed care or another health care setting.
Legal or regulatory background or experience highly desired.
Strong written and verbal communication skills; public speaking/educator experience desired.
Ability to interpret and apply Federal law and regulatory requirements ensuring compliance with Medicare Managed care obligations.
Ability to educate staff, providers, and enrollees about the appeals and grievance process.
Familiarity with claims processing, coordination of benefits, and use of claims processing system.
Ability to follow Federal guidelines from CMS and Ohio Department of Insurance (ODI) for appeal and grievance resolution processes and requirements.
Equal Opportunity Statement
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, or basis of disability or any other federal, state, or local protected class.
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