Appeals & Grievances Specialist II

Metropolitan Jewish Health System, Inc.; New York (NY); Presencial; USD 55.000 - 70.000; Jornada completa

Descripción de la vacante

Metropolitan Jewish Health System, Inc. is seeking an Appeals & Grievances Coordinator to manage non-clinical aspects of member and provider appeals, ensuring accurate intake, validation, and timely processing in compliance with CMS, DOH, and internal policies.

The role supports member advocacy by coordinating case setup, triage, documentation, letter drafting, and correspondence with clinical and operational teams to maintain high accuracy and regulatory adherence.

Formación

• Associates Degree required; BA/BS preferred.
• Minimum 2 years A&G or Member Service experience required.
• Knowledge of Medicare or Medicaid

Responsabilidades

• Review newly created cases to confirm accurate classification or reassignment to correct classification as necessary.
• Review history and identify additional information that may be required as part of the investigation.
• Respond in a timely manner to written and/or verbal appeals and grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations.
• Documents all relevant information in the Appeals and Grievances determination process within the appropriate designated areas of the A/G system.
• Maintain regulatory compliance and company policy through thoughtful management of assigned caseload.
• Presents cases to the Appeals & Grievances File Review Team as needed.
• Successfully complies with the accuracy of case files in key performance indicators during monitoring and auditing activities (95% of audited case files)
• Meet or exceed timeliness standards for all assigned cases

Educación

Associates Degree

BA/BS Degree preferred

Descripción del empleo

Metropolitan Jewish Health System, Inc. is seeking an Appeals & Grievances Coordinator to manage non-clinical aspects of member and provider appeals, ensuring accurate intake, validation, and timely processing in compliance with CMS, DOH, and internal policies.

The role supports member advocacy by coordinating case setup, triage, documentation, letter drafting, and correspondence with clinical and operational teams to maintain high accuracy and regulatory adherence.