Grievance & Appeals Compliance Specialist

Neighborhood Health Plan of Rhode Island; Smithfield (RI); On-site; USD 55,000 - 75,000; Full time

Job summary

Neighborhood Health Plan of Rhode Island is seeking a Grievance and Appeals Coordinator to support the GAU by managing intake, assignment, tracking, and timely communications across Medicaid, Medicare, and Commercial lines.

The role ensures compliant early resolutions, maintains secure records, coordinates with internal teams and external entities, and provides training as needed to strengthen the grievance and appeals process. Evening/weekend coverage may be required.

Qualifications

• Associates degree or equivalent work experience.
• Strong analytical skills with ability to identify issues, collect data, and draw valid conclusions.
• Basic knowledge of medical terminology and CPT/ICD-10 coding.
• Familiarity with state and federal laws related to grievances and appeals.
• Excellent organizational, prioritization, and time management skills.
• Strong customer service orientation and professional communication skills.
• Proficient in Microsoft Office (Excel, Word, PowerPoint, Outlook).
• Experience with healthcare management systems and ability to learn proprietary platforms.

Responsibilities

• Handle intake and process Medicaid, Medicare, and Commercial appeals, grievances, and complaints.
• Scan and convert paper submissions to electronic format for processing.
• Generate timely acknowledgement letters (verbal and/or written).
• Track and monitor all cases electronically with accurate documentation.
• Manage external appeals across lines, ensuring timely resolution and compliance.
• Follow up with internal departments and delegated entities to meet deadlines.
• Monitor GAU forms with legal department for appropriateness.
• Provide training to new team members as needed.

Skills

Analytical skills

Organizational skills

Customer service

Microsoft Office

CPT/ICD-10 coding

Regulatory compliance

Communication

Education

Associates degree or equivalent work experience

Tools

Healthcare management systems

Electronic health record platforms

Job description

Neighborhood Health Plan of Rhode Island is seeking a Grievance and Appeals Coordinator to support the GAU by managing intake, assignment, tracking, and timely communications across Medicaid, Medicare, and Commercial lines.

The role ensures compliant early resolutions, maintains secure records, coordinates with internal teams and external entities, and provides training as needed to strengthen the grievance and appeals process. Evening/weekend coverage may be required.