Appeals & Grievances Coordinator

Nirvana Health Ltd.; Southborough (MA); On-site; USD 55,000 - 70,000; Full time

Job summary

Mass Digital Health in Massachusetts is seeking an Appeals & Grievances Coordinator to help support the intake, review, and resolution of member and provider appeals and grievances. You'll work closely with various teams while ensuring compliance with CMS-mandated timelines and executing case management processes.

The ideal candidate will have 1-3 years of related experience, strong professional writing skills, and familiarity with CMS regulations. This position requires detail orientation and effective communication across teams.

Qualifications

• 1–3 years of related experience in Appeals & Grievances case management.
• Familiarity with CMS guidance and Medicare Part C & D regulations.
• Strong professional writing skills for drafting letters.

Responsibilities

• Manage cases end-to-end for member and provider appeals and grievances.
• Draft clear and compliant member-facing communications.
• Collaborate with cross-functional teams to build complete case folders.

Skills

Critical thinking

Detail orientation

Effective verbal communication

Strong professional writing skills

Education

Bachelor's degree or equivalent experience

Tools

Microsoft Office (Excel, Word, Outlook)

Job description

Job Summary

nirvanaHealth is rebuilding the payer enterprise on a digital workforce. Our cloud-native Aria platform delivers payer administrative and care-continuum functions as Transaction-as-a-Service (TaaS) — combining robotic process automation, machine learning, and agentic AI to execute the thousands of transactional functions that currently consume payer operating margin. We operate across Medicare Advantage, Medicaid, Commercial, ASO, and ACA lines of business.

As an Appeals & Grievances (A&G) Coordinator, you will help support the intake, review, and resolution of member and provider appeals and grievances while ensuring cases are handled accurately, compliantly, and within CMS-mandated timelines. In this role, you will work closely with the VP of Health Services and partner across clinical, compliance, operations, and customer service teams while using Aria’s A&G module and emerging AI‑assisted workflows to support member rights and deliver audit‑ready outcomes. This position also supports delegated operations, requiring adaptability across process variations while maintaining consistent regulatory compliance.

Job Responsibilities

• Manage cases end-to-end — Receive, document, investigate, and resolve member and provider appeals (Part C and Part D) and grievances submitted via phone, fax, email, mail, or portal. Track and enforce CMS timeliness.
• Draft member-facing communications — Draft acknowledgment and resolution letters that are clear, empathetic, and fully compliant with CMS, state, and accreditation (NCQA/URAC) requirements.
• Collaborate cross-functionally — Partner with Medical Directors, Compliance, Pharmacy, Utilization Management, Customer Service, and external review bodies to build complete case folders and drive meaningful outcomes.
• Support delegated operations — Execute A&G processes across delegated environments, maintaining process variations where needed while adhering to standard operating procedures.
• Prepare evidence for external review — Compile and organize case files for IRE auto‑forwards and external audit bodies.
• Leverage emerging tools — In addition to MS Office and other Windows-based tools, utilize emerging tools to drive quality and productivity.
• Surface insights and support reporting — Compile data for regulatory reporting, help identify trends, and contribute to quality improvement initiatives.

Qualifications

• Education
  • Required —
  • Preferred Bachelor's degree or equivalent experience
• Experience
  • Required 1–3 years of related experience
  • Preferred Hands‑on A&G case management, prior auth, or compliance/quality experience; Medicare Advantage, Medicaid, or Commercial plan environment
• Regulatory Knowledge
  • Required Working familiarity with CMS guidance, Medicare Part C & D regulations, member rights under 42 CFR Sections 422/423
  • Preferred NCQA and/or URAC accreditation standards; Massachusetts state requirements (MassHealth, DOI, Office of Patient Protection)
• Writing & Communication
  • Required Strong professional writing skills — you will draft acknowledgment, resolution, and determination letters daily; effective verbal communication with members, providers, clinical staff, and external agencies
  • Preferred —
• Tools & Technology
  • Required Microsoft Office (Excel, Word, Outlook); comfort with case management and tracking systems
  • Preferred Healthcare payer platform experience
• Core Competencies
  • Required Detail orientation under regulatory deadlines; critical thinking in case investigation; high‑volume caseload management; de‑escalation & customer service orientation; HIPAA/PHI compliance
  • Preferred —