Appeals Coordinator - Nurse

Wollborg Michelson Recruiting; Phoenix (AZ); On-site; USD 42,000 - 62,000; Full time

Job summary

Wollborg Michelson Recruiting is seeking a Medical Appeals and Grievances Support Specialist to review, research, and resolve medical and pharmacy appeals and grievances. The role involves examining medical records, claims information, and regulatory requirements to determine case resolution, while maintaining HIPAA compliance.

Applicants should have experience in claims processing or related fields and a background in healthcare documentation.

Qualifications

• At least one year of experience in claims processing, medical or pharmacy precertification, appeals and grievances coordination, or a related field.
• High school diploma or equivalent; higher education acceptable.
• Professional certification such as Coder certification is preferred.

Responsibilities

• Research and resolve medical and pharmacy appeals and grievances from members and providers.
• Review medical records, claims data, and supporting documentation to determine case resolution.
• Process appeals in accordance with state, federal, regulatory, and contractual requirements.
• Prepare case files, communications, and documentation for medical directors and regulatory agencies.
• Monitor appeals channels, identify trends, and assist with quality improvement initiatives.

Skills

Claims processing

HIPAA compliance

Analytical research

Written communication

Customer service

Interpersonal skills

Confidentiality

Team collaboration

Medical terminology

Education

High school diploma

Certified Coder (preferred)

Tools

Claims systems

Pharmacy systems

Medical management systems

Microsoft Office

Job description

Medical Appeals and Grievances Support Specialist Job Summary

Supports the review, research, processing, and resolution of medical and pharmacy appeals and grievances. Conducts investigations, reviews medical records and claims information, maintains regulatory compliance, identifies trends, and provides administrative and analytical support for complex appeals, legal inquiries, audits, and accreditation reviews.

Responsibilities

Research and resolve medical and pharmacy appeals, grievances, and related inquiries from members, providers, and external organizations. Review medical records, claims, coverage guidelines, historical data, and supporting documentation to determine case resolution. Process appeals and grievances in accordance with applicable state, federal, regulatory, accreditation, and contractual requirements. Prepare records, case files, written communications, and supporting documentation for medical directors, legal teams, regulatory agencies, audits, and accreditation reviews. Process data corrections, initiate claims adjustments, and coordinate resolutions with the appropriate departments. Research and reopen claims appeals involving diagnosis mismatches. Use medical management, claims, pharmacy, and other systems to research, document, track, and update cases. Process Level 1 reviews and support Level 2 and external pharmacy case preparation. Monitor assigned appeals and grievance communication channels, proxy boxes, and telephone queues. Identify and report trends in appeals, grievances, insufficient records, and medical documentation to management. Assist with utilization studies, quality sampling audits, aging reports, case assignments, and related analyses. Assist with customer inquiries, reviewer questions, training activities, and staff mentoring. Create job aids and help maintain department procedures and reference materials. Communicate with vendors, special groups, privacy personnel, and legal teams as directed. Maintain confidentiality and ensure compliance with HIPAA and protected health information requirements. Maintain current knowledge of medical terminology, claims processing, business lines, regulatory requirements, appeal timeframes, and grievance procedures. Complete required and additional training, demonstrate competency, and participate in professional development activities. Meet department performance goals while working independently with limited supervision and maintaining a commitment to excellent customer service.

Requirements

At least one year of experience in claims processing, medical or pharmacy precertification, appeals and grievances coordination, or a related field. High school diploma or equivalent required;a higher level of education is acceptable. Professional certification, such as Certified Coder, is preferred.

Preferred experience

Preferred experience includes two years in a lead or senior claims role. Preferred experience includes three years of claims processing and correspondence using multiple claims systems. Preferred experience includes two years in a medical or healthcare-related field. Preferred experience includes three years as a pharmacy technician or precertification technician.

Skill

Intermediate computer proficiency and experience using office equipment. Intermediate proficiency with word processing, spreadsheet, database, claims, medical management, and pharmacy systems. Strong written communication, correspondence, and letter-writing skills. Ability to conduct investigative and analytical research. Ability to interpret and apply policies, procedures, programs, benefits, and administrative guidelines. Knowledge of claims processing logic and healthcare operations. Ability to navigate, gather, enter, and maintain information in multiple systems. Strong interpersonal, active listening, collaboration, and customer service skills. Ability to maintain confidentiality and protect personal health information. Ability to establish effective working relationships in a team environment. Advanced computer, database, spreadsheet, and written communication skills are preferred. Experience in a lead or senior claims position is preferred.

Summary Qualification

Demonstrated experience reviewing and resolving healthcare claims, appeals, grievances, or precertification requests. Ability to analyze medical records, claims data, coverage guidelines, and regulatory requirements. Strong attention to detail, organization, documentation, and follow-through. Ability to manage confidential information and meet strict processing deadlines. Effective communication skills for working with members, providers, internal departments, vendors, and regulatory or legal representatives. Ability to work independently, support team operations, and contribute to quality improvement initiatives.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.