Coordinator - Appeals & Grievances - MediGold Health Plan

Mount Carmel Health System; Columbus (OH); On-site; USD 50,000 - 70,000; Full time

Job summary

Join a leading healthcare organization as a Coordinator for Appeals & Grievances, managing member and provider disputes. This full-time role at Mount Carmel Health System emphasizes effective communication and compliance with CMS regulations. Ideal for candidates with a strong background in customer service and healthcare.

Benefits

Competitive salary

Comprehensive benefits

Retirement plans

Paid time off

Tuition reimbursement

Qualifications

• At least three years in customer service or appeals/grievance experience, preferably in managed care.
• Strong communication skills and ability to interpret federal regulations.
• Experience with claims processing and CMS regulatory guidelines.

Responsibilities

• Manage processing and resolution of appeals and grievances.
• Document and route cases to appropriate clinical staff.
• Ensure compliance with CMS guidelines and regulatory requirements.

Skills

Communication

Analytical Skills

Regulatory Knowledge

Education

Bachelor’s degree or equivalent experience

Job description

Coordinator - Appeals & Grievances - MediGold Health Plan

Join to apply for the Coordinator - Appeals & Grievances - MediGold Health Plan role at Mount Carmel Health System.

About MediGold: MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. We focus on providing excellent customer service, cost-effective care, and exceptional healthcare coverage, employing professionals in various fields including information technology, financial analysis, audit, and provider relations.

Employment Type: Full-time

Shift: Not specified

Position Purpose

The Appeals and Grievance Coordinator manages the processing and resolution of appeals, grievances, and disputes from members and providers.

Key Responsibilities

• Document appeal requests or grievances and route cases to appropriate clinical staff.
• Obtain and manage confidential medical records securely.
• Prepare case files and review with clinical colleagues.
• Ensure all grievances, appeals, and provider disputes comply with CMS guidelines and policies.
• Gather, analyze, and report complaints, grievances, and appeals within federal timeframes.
• Conduct investigations and prepare documentation for review by the Independent Review Entity (IRE), Appeals Committee, and ALJ hearings.
• Prepare data for CMS audits and participate in monitoring and reporting efforts.
• Maintain compliance with all regulatory requirements related to appeals and grievances.

Minimum Qualifications

• Bachelor’s degree or equivalent experience.
• At least three years in customer service or appeals/grievance experience, preferably in managed care or healthcare.
• Strong communication skills and ability to interpret federal regulations.
• Experience with claims processing and regulatory guidelines from CMS and ODI.

Benefits

• Competitive salary and comprehensive benefits from day one.
• Retirement plans, paid time off, tuition reimbursement, and more.
• Employee recognition, referral programs, and daily Pay option.

About Mount Carmel

With over 135 years of service, Mount Carmel provides healthcare across Ohio, including hospitals, outpatient facilities, and educational programs. We are committed to diversity, equity, inclusion, and equal opportunity employment.