Grievance and Appeals Coordinator III

Job Description

Job Description

Grievance and Appeals Coordinator III
Pay Rate: $40.00 – $42.00/hour
Schedule: Monday – Friday, 8:00 AM – 5:00 PM

Under the general direction of the Grievance and Appeals Supervisor, the Grievance and Appeals (G&A) Coordinator III is responsible for reviewing, analyzing, and processing complex, quality of care, and high-level grievances and appeals across all lines of business. This role includes preparing written communications that clearly convey case determinations.

The Coordinator independently manages and monitors the grievance and appeals process to ensure quality, regulatory compliance, and accuracy while working collaboratively within a team environment.

Principal Responsibilities

• Address and respond to telephonic and written inquiries regarding complex, quality of care, and high-level grievances, adverse benefit determination appeals, and expedited concerns
• Ensure accurate identification and categorization of issues raised by members, member representatives, or providers
• Independently investigate, research, review, and resolve complex cases within regulated timeframes
• Clarify issues and educate members on the grievance and appeals process
• Handle escalated member and provider concerns with a focus on satisfaction and retention
• Research and apply key policy provisions including clinical guidelines, plan policies, Evidence of Coverage (EOC), regulatory standards, and DMHC/DHCS rules and regulations
• Interpret member contracts, internal policies, procedures, and accreditation requirements
• Summarize cases, clearly articulate the member’s perspective, and prepare clinical cases for RN and Medical Director review
• Maintain frequent communication with members from case intake through resolution
• Generate written correspondence to members, providers, and regulatory agencies in compliance with regulatory standards and contractual obligations
• Interpret and explain health plan benefits, policies, procedures, and functions verbally and in writing
• Identify system or operational issues that impact care delivery or service expectations
• Thoroughly document investigations and resolutions in the electronic database
• Maintain complete and accurate appeals and grievance records
• Coordinate and prepare documentation for State Fair Hearings, MAXIMUS reviews, Independent Medical Reviews (IMR), and DMHC appeal processes
• Ensure compliance with all state and federal regulations related to grievance and appeal issues
• Serve as liaison with internal departments to resolve issues
• Communicate potential risk or operational impact concerns to the Supervisor in a timely manner
• Mentor new hires or team members as assigned
• Provide support to the Team Lead and Supervisor
• Participate in special projects and other duties as assigned

Essential Functions

• Manage a caseload of a minimum of 30 complex cases per month
• Coordinate grievance and appeal activities by receiving, handling, and resolving member and operational issues
• Meet compliance, quality, and productivity standards
• Ensure all cases and correspondence meet accreditation, regulatory, contractual, and timeliness requirements
• Maintain organized, confidential, and secure case files and documentation
• Perform ongoing data entry
• Comply with the organization’s Code of Conduct, regulatory requirements, and internal policies and procedures

Education & Experience

Education:

• High school diploma or equivalent required
• Associate’s or Bachelor’s degree preferred

Experience:

• Minimum of 2–3 years of Grievance and Appeals Coordinator experience required

If you are interested, please reach out to Chin Yang at A-Line Staffing. 586-323-4194 | cyang@alinestaffing.com.