Appeals Operations Lead & Quality Coach

1199seiu; New York (NY); On-site; USD 70,000 - 100,000; Full time

Job summary

1199SEIU is seeking an Appeals Coordinator to partner with the Manager in achieving department and fund goals. You will guide 1st- and 2nd-level appeals, analyze production metrics, and resolve escalated issues with stakeholders including members, providers, and attorneys.

The role emphasizes compliance with DOL and ERISA, policy improvement, and coaching for staff to ensure accurate determinations and timely responses in a fast-paced environment.

Qualifications

• Bachelor’s degree in health care or related field, or equivalent years of work experience.
• 4+ years’ experience in claims adjudication, health care claims auditing, or benefit administration.
• 2+ years in Healthcare Appeals/Grievances environment preferred.
• Advanced knowledge of QNXT navigation and modules.
• Extensive knowledge of health claims policies and COB rules.
• Intermediate skills in Word and Excel.
• Strong knowledge of Medical Claims Processing Systems (QNXT) and coding (ICD-9/10, CPT).
• Strong critical thinking and analytical abilities.
• Effective verbal and written communication skills.
• Time and project management, detail-oriented, multitasking in fast-paced settings.
• Quality control and auditing procedures experience preferred.

Responsibilities

• Partner with the Manager to implement Appeals Department and Fund goals.
• Serve as a resource on 1st- and 2nd-level appeals for complex cases.
• Evaluate and monitor production, aging, and escalated reports; provide analytical insights.
• Resolve escalated calls and liaise between staff and Management; follow up on urgent matters.
• Daily monitoring of calls; generate reports and coach staff with Listening Sessions.
• Recommend policy/procedure improvements; train staff on updated workflows and compliance.
• Quality reviews with other Appeal Coordinators to ensure audit guidelines and data accuracy.
• Communicate orally and in writing with members, providers, vendors, attorneys, on appeals process and updates.
• Perform additional duties and projects as assigned by management.

Skills

Claims adjudication

Healthcare claims auditing

Benefit administration

Healthcare Appeals/Grievances

MS Word

MS Excel

QNXT navigation

Medical Codes

ICD-9/10

CPT codes

Auditing procedures

Education

Bachelor's degree in health care

Tools

QNXT

Microsoft Word

Microsoft Excel

Job description

1199SEIU is seeking an Appeals Coordinator to partner with the Manager in achieving department and fund goals. You will guide 1st- and 2nd-level appeals, analyze production metrics, and resolve escalated issues with stakeholders including members, providers, and attorneys.

The role emphasizes compliance with DOL and ERISA, policy improvement, and coaching for staff to ensure accurate determinations and timely responses in a fast-paced environment.