Sr Coordinator, Complaint & Appeals Operations

Prepares information and reports needed to address matters regarding complaints, appeals, and grievances. Carries out policies, procedures, and programs to ensure compliance with federal and/or state regulations.

What you will do

• Conducts team reviews, interpretations, and appeals filed by patients, escalating more complex issues and concerns to management for review and follow-up.
• Ensures adherence to regulatory requirements, conducts internal audits, and addresses any identified compliance issues with the Complaint and Appeals policies and procedures.
• Facilitates in-depth reviews of decisions and case files to determine if there are errors or anomalies in the application of law or evidence.
• Oversees the drafting and progression of appeal decision letters, conducting detailed follow-up for timely and thorough follow-up and resolution.
• Monitors key performance indicators (KPIs) and metrics to evaluate the effectiveness and efficiency of the appeals and grievances process.
• Ensures all front-line associates promptly and accurately respond to all patient billing questions and concerns.
• Facilitates and provides educational materials, training programs, and presentations to enhance understanding of the appeals and grievances process.
• Coaches and mentors other colleagues in techniques, processes, and responsibilities for effectively handling member complaints and appeals.
• Trains junior-level staff to promote the development of departmental capabilities.

For this role you will need Minimum Requirements

• 5+ years work experience
• Adept at problem solving and decision making skills 

Education

• High school diploma or equivalent required.