Appeals & Grievances Coordinator

Florida Blue; Florida; On-site; USD 28,000 - 45,000; Full time

Benefits offered by this job

Medical, dental, vision insurance

Life and disability insurance

Paid time off

Retirement plan with employer match

Holidays and well-being days

Voluntary benefits

Job summary

Florida Blue seeks a Medicare Appeals and Grievances Coordinator to resolve member and provider appeals and grievances in compliance with CMS timelines. You will manage case loads, gather medical records, and coordinate with vendors and partners to reach timely determinations.

Strong Medicare knowledge and data-driven problem solving are essential. You will work across systems like Siebel, JIVA, Diamond, and ProviderConnect to document actions and communicate outcomes to appellants, while

Qualifications

• 3+ years related work experience in Member Contact, Enrollment, Maintenance and Billing (EM&B), Claims or Medicare.
• Experience using Siebel, Diamond, JIVA and other Medicare databases.
• Ability to work flexible schedule with overtime and weekends when needed.
• Medicare product knowledge.
• Ability to work independently and collaboratively as a team member.
• Excellent interpersonal skills and an ability to recognize, understand, and respond to sensitive member issues or concerns.
• Ability to manage multiple priorities, have analytical and problem solving skills with attention to detail.

Responsibilities

• Review appeal and grievance cases from various appellant types in accordance with CMS guidelines and timeframes.
• Classify cases and review for potential expedited requests.
• Resolve complex standard or expedited grievances, appeals or disputes.
• Coordinate with CMS regulatory guidelines and required notices to meet CMS timeframes.
• Prioritize case workload to ensure CMS timeframes and written notifications are met.
• Access various systems to gather pertinent data related to the case and document resolution.
• Research and document pertinent details and attach supporting documents to the case.
• Coordinate with internal partners and gather data or medical records for clinical decisions.
• Ensure notification to the appellant within CMS timeframes.
• Outreach to members, providers, and partners to resolve appeals or grievances.
• Escalate issues to Manager as needed.

Skills

Analytical thinking

Problem solving

Communication

Team collaboration

Education

Bachelor's degree

High school diploma or GED

Tools

Siebel

Diamond

JIVA

ProviderConnect

Client Letter

ERCMS RADMD

Magellan

Blue 2

Job description

We seek contributors who deliver results with accountability while collaborating seamlessly across boundaries. They embrace change with resilience, staying curious and learning continuously in a rapidly evolving landscape. Grounded in business understanding and comfortable with AI and digital tools, they solve problems with critical thinking and creativity. Above all, they are driven to serve-ensuring their work creates meaningful impact for members and the community we support.

The primary responsibilities of a Medicare Appeals and Grievances Coordinator are centered on daily resolution of Medicare member, member's representatives (which can be a treating physician) and non-participating provider's appeals and grievances in compliance with applicable CMS timeframes and regulations. The Medicare Appeals & Grievances Coordinator is accountable for inventory prioritization of case load to meet various CMS and OIR required SLAs, gathering applicable information related to the case, working with appellants and delegated vendors to obtain for medical records, tracking effectuations, and meeting strict written and oral notification requirements.

What You Will Be Doing

• Review appeal and grievance cases from various appellant types (member, member representative, treating physician and non-participating providers) in accordance with CMS regulatory guidelines and timeframes.
• Must ensure cases are classified correctly and reviewed for potential expedited requests.
• Resolves complex standard or expedited grievances, appeals or disputes involving expressions of dissatisfaction, reimbursement, medical necessity,
• Utilization Management and benefits from the various appellant types (member, member representative, treating physician and non-participating providers) in accordance with CMS regulatory guidelines and timeframes.
• Prioritize case workload to ensure CMS timeframes and required written notifications are met for various case types:
  • Standard Pre-Service Appeals
  • Expedited Pre- Service Appeals
  • Post Service appeals
  • Payment Disputes
  • MA Grievances
  • Med Supp Grievances
• Access various systems such as: MAAGC, JIVA, Diamond, ProviderConnect, Client Letter, ERCMS RADMD, Magellan, and Blue 2 in order to gather pertinent data related to the case and document resolution.
• Conduct a thorough research and accurately document pertinent details to include research details, action taken for resolution or outreach to various business partners and attach supporting documents to the case
• Coordinates with internal business partners and provides case details, gathers required data or medical records for cases related to clinical decisions, delegated vendors, claims, network, etc.
• Ensure proper research is completed with documentation of supporting details to render a final determination with verbal and/or written notification to the appellant within the CMS timeframes
• Perform outreach to members, providers, internal and external business partners in order to complete resolution of appeal or grievance
• Facilitates escalated calls and issues from providers and/or members regarding appeals or dispute decisions. Escalates any issues or phone calls to the Manager as needed.

What We Require

• 3+ years related work experience in experience in Member Contact, Enrollment, Maintenance and Billing (EM&B), Claims or Medicare experience. High school diploma or GED
• Additional Required Qualifications
• Experience using Siebel, Diamond, JIVA and other Medicare databases.
• Ability to work flexible schedule with overtime and weekends when needed
• Medicare product knowledge
• Ability to work independently and collaboratively as a team member
• Excellent interpersonal skills and an ability to recognize, understand, and respond to sensitive member issues or concerns
• Ability to manage multiple priorities, have analytical and problem solving skills with attention to detail

What We Prefer

• Bachelor's degree
• Strong working knowledge of Medicare Advantage/ Supplement/ Frozen Products, CMS, OIR, DFS and other regulatory requirements
• Proven organizational skills with strong attention to detail
• Proven ability to work independently, collaboratively and use appropriate judgment to make independent decisions by following guidelines Intermediate PC skills (MS Word, Excel, PowerPoint) Hands-on experience processing Medicare Claims, Written Inquiries or EMB transactions
• Current Experience with JIVA, Diamond, ProviderConnect, CustomerConnectClient Letter, ERCMS RADMD, Magellan, and Blue 2

General Physical Demands

• Exerting up to 10 pounds of force occasionally to move objects.
• Jobs are sedentary if traversing activities are required only occasionally.
• Team schedules are determined based on role requirements and business needs. Travel to and from our corporate offices may be required.

What We Offer

As a Florida Blue employee, you will be at the heart of GuideWell's vision - to lead the nation in transforming health through compassionate, connected, and technology-enabled care that delivers personalized value and empowered living.

To support your wellbeing, comprehensive benefits are offered. As an employee, you will have access to:

• Medical, dental, vision, life and global travel health insurance
• Income protection benefits: life insurance, short- and long-term disability programs
• Leave programs to support personal circumstances
• Retirement Savings Plan including employer match
• Paid time off, volunteer time off, 10 holidays and 2 well-being days
• Additional voluntary benefits available; and a comprehensive wellness program

Employee benefits are designed to align with federal and state employment laws. Benefits may vary based on the state in which work is performed. Benefits for intern, part-time and seasonal employees may differ.

To support your financial wellbeing, we offer competitive pay as well as opportunities for incentive or commission compensation. We also conduct regular annual reviews with pay for performance considerations for base pay increases.

Typical Hourly Offer/Pay Range: $20 - $25

Hourly Pay Range: $20 - $33

Final pay will be determined with consideration of market competitiveness, internal equity, and the job-related knowledge, skills, training, and experience you bring.

We are an Equal Employment Opportunity employer committed to cultivating a work experience where everyone feels like they belong and can perform at their best in pursuit of our mission. All qualified applicants will receive consideration for employment.