Appeals and Grievances Coordinator
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Job Description
Primary contact for members, providers, and clients in the appeals and grievances process at Avesis. Timely resolution of dental and vision A&G cases within a regulated managed care environment.
Responsibilities:
- The Appeals and Grievances Coordinator is the primary point of contact for members, providers, and clients throughout the appeals and grievances process.
- Provide timely, accurate, and compliant resolution of dental and vision A&G cases within a regulated managed care environment.
- 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.
- Draft formal correspondence such as acknowledgement and resolution notices.
Requirements:
- 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.
Benefits:
- 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.
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