VetJobs is hiring: Coordinator Appeals & Grievances - Hybrid - Philadelphia, PA

Coordinator Appeals & Grievances - Hybrid - Philadelphia, PA

Join to apply for the Coordinator Appeals & Grievances - Hybrid - Philadelphia, PA role at VetJobs.

Job Description

On behalf of VetJobs/MilitarySpouseJobs, thank you for your interest. We are assisting our partnering company, listed below, with this position. It is open to Veterans, Transitioning Military, National Guard Members, Military Spouses, Wounded Warriors, and their Caregivers. If you have the required skill set, education requirements, and experience, please click the submit button and follow for next steps.

Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission‑driven organization with more than 30 years of experience. We deliver comprehensive, outcomes‑driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Responsibilities

• Reporting to the Supervisor, Appeals and Grievances, this position is responsible for the administrative tasks for coordination of member and/or provider appeals, the analysis of claims and appeals, and the review of medical management authorizations.
• Research and investigate member and/or provider appeals and grievance requests, including review of UM/claim denial reasons, contract/regulatory rules, benefits, and documentation received on appeal/grievance.
• Distribute meeting materials, reports, and follow‑up documentation as needed.
• Facilitate, manage, and guide panel meetings (i.e., telephonic, video conference and in‑person) by enforcing guidelines, fostering order and engagement, and ensuring smooth and cohesive discussion.
• Communicate effectively with panel members, stakeholders, and leadership to ensure alignment and clarity of appeal(s).
• Maintain confidentiality, organization, and integrity in handling sensitive information.
• Upload recording, documentation, and transcription to capture key discussions and decisions.
• Make outreach calls to members/participants, providers, and/or member/participant representatives to acknowledge receipt of appeal/grievance and discuss intent of appeal/grievance.
• Explain the appeal/grievance process, helping members understand the outcome and implication of appeals decisions.
• Prepare case file (original denial, all information received on appeal, medical records, etc.).
• Schedule participants/members for committee panel, sending scheduling letters if needed.
• Prepare, develop, and present written case summaries for all adverse determinations to conduct State Fair Hearings.
• Prepare and send case files to other teams as needed (e.g., legal, external appeals, state fair hearings).
• Communicate updates and status of outstanding member and provider complaints/issues to management.
• Monitor to ensure all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures.
• Update and/or generate authorization updates requests for services that have been appealed.
• Maintain accurate, timely, and complete record of appeals and grievances in the appeals system and document all correspondence with a member/participant, representative and/or a provider related to an appeal or grievance issue.
• Maintain quality and compliance standards as dictated by the state and federal entities.
• Maintain contractual agreements with participating providers related to appeals and grievances.
• Monitor caseload daily to ensure all cases are kept within compliance; follow up and elevate when compliance standards are at risk.
• Actively seek involvement of the legal or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management.
• Obtain authorization for release of sensitive and confidential information.
• Keep current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances.
• Ensure case file is sent to appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director – as process dictates.
• Provide support presenting cases and facilitating committee meetings as needed.
• Send appeal to an independent review organization portal, for those appeals that require an external match specialty review.
• Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained, e.g., PerformRX, LTSS and other systems/vendors as needed.
• Collaborate with internal counterparts as needed to ensure proper handling of the appeal e.g., UM team, medical directors, claims, contact center, vendors as needed (e.g., PerformRX).
• Creates decision letter with detail description of the nature of appeal/grievance including rationale for the decision and options for moving forward.
• Initiate and follow up on effectuations (UM authorization update/claim adjustment) for overturned appeals/grievances.

Education & Experience

• Required: High School/GED.
• Required: A minimum of two (2) years’ work experience in a Managed Care environment.
• Required: 1 to 3 years’ experience in Grievance/appeals environment.

Ideal Candidate

• Proven experience as a facilitator or moderator.
• Experience organizing and managing meetings.
• Excellent verbal and written communication skills.
• Ability to engage and manage diverse groups.
• Awareness and sensitivity to diverse cultural backgrounds.
• Ability to create a positive environment.
• Ability to handle challenging situations and conflict constructively.
• Familiarity with presentation software, video conferencing tools (Zoom & Teams) and relevant technology.
• Proficiency with Windows and Microsoft Office applications, including Excel, Access, PowerPoint and Outlook.
• Knowledge of the basic health care industry, managed care principles, claims, and medical terminology.
• Ability to work collaboratively or independently; deliver high‑quality work; attention to detail and flexibility; excellent verbal and written communication skills.

Benefits

Flexible work solutions including remote options, hybrid work schedules, competitive pay, paid time off including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement and more.