Grievance & Appeals Coordinator

WPS—A health solutions company; North Carolina; Remote; Full time

Job summary

A leading health solutions company is seeking a Grievance & Appeals Coordinator to manage patient grievances and appeals related to claims and authorizations. This remote-friendly role requires strong communication and investigative skills to support both members and providers, ensuring fair resolutions while adhering to regulations and improving internal processes.

Benefits

Remote and hybrid work options

401(k) with competitive matching

Health, dental, and telehealth services starting day 1

Professional development opportunities

Qualifications

• 2+ years in claims processing or related role in health insurance.
• Familiarity with federal/state regulations governing health insurance.
• Excellent verbal and written communication skills.

Responsibilities

• Investigate and resolve complex complaints related to claims.
• Act as a liaison between members and insurance providers.
• Prepare and maintain reporting processes to support company savings.

Skills

Researching skills

Investigative skills

Communication

Problem-solving

Organizational skills

Education

High School Diploma or equivalent

Associate's degree or higher in healthcare administration or related field

Job description

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Join to apply for the Grievance & Appeals Coordinator role at WPS—A health solutions company

As a Grievance and Appeals Coordinator, you will investigate and resolve complex patient and insurance provider complaints related to claims, enrollment, medical authorization denials, within the healthcare industry. You will act as a liaison between the member, insurance provider, and medical service providers to ensure timely and fair resolution of all appeals and grievances. Reporting processes will be created and maintained in this role to support the overall savings for the company while maintaining the membership and provider support of our company.

Hourly Rate of Pay

$22.00/hour - $27.00/hour

Work Location

We are open to remote work in the following approved states:

Arizona, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Michigan, Minnesota, Missouri, Nebraska, Nevada, New Jersey, North Carolina, North Dakota, Ohio, South Carolina, South Dakota, Texas, Virginia, Wisconsin

How do I know this opportunity is right for me? If you:

• Have efficient researching and investigative skills.
• Can communicate with confidence, clarity and sound reasoning when resolving an issue.
• Are a self-starter, work independently, and can reprioritize as new situations arise.
• Have experience with regulatory information and are familiar with healthcare data such as PHI and PII.
• Have strong skills and technical acumen that could include the following skillsets: computer navigation and working within multiple applications, telephone support, letter writing and composition, project management.
• Have strong organizational skills and documentation.
• Are able to learn new products and processes.
• Want to be an innovator helping to bring process improvements and develop reporting and tracking strategies.
• Approach situations with empathy and adaptability in mind.
  
  

What will I gain from this role?

• Deep understanding of the WPS certificates and Medical Policies.
• Hands on experience in resolving grievances and appeals for our members.
• The opportunity to participate in professional development and training.
• Independence to solve problems investigate issues and utilize sound decision making skills constantly.
• Knowledge and participation of audits with Utilization Review Accreditation Commission (URAC).
• Working on a diverse team environment of clinical staff including Nurses, Medical Directors, Quality and Intake Specialists.
• Opportunities to learn, train and create process improvements and best practices to the division.
• Experience working in an environment that serves our nation’s military, veterans, Guard and Reserves, and Medicare beneficiaries.
• Working in a continuous performance feedback environment.
  
  

Minimum Qualifications

• High School Diploma or equivalent.
• 2 or more years of experience in claims processing, customer service, or a related role in the health insurance industry.
• Familiarity with federal and state regulations governing health insurance claims and member rights.
• Excellent communication skills, both written and verbal, with the ability to explain complex information to members in an understandable way.
• Strong problem-solving skills and attention to detail with the ability to manage multiple cases and meet deadlines.
  
  

Preferred Qualifications

• Associate's degree or higher in healthcare administration, business, or related field.
• 3 years or more of professional work experience within healthcare, insurance or appeals.
• Experience with grievance and appeals processes, insurance regulations, and claims adjudication.
  
  

Remote Work Requirements

• High speed cable or fiber internet
• Minimum of 10 Mbps downstream and at least 1 Mbps upstream internet connection (can be checked at https://speedtest.net)
• Please review Remote Worker FAQs for additional information
  
  

Benefits

• Remote and hybrid work options available
• Performance bonus and/or merit increase opportunities
• 401(k) with a 100% match for the first 3% of your salary and a 50% match for the next 2% of your salary (100% vested immediately)
• Competitive paid time off
• Health insurance, dental insurance, and telehealth services start DAY 1
• Employee Resource Groups
• Professional and Leadership Development Programs
• Review additional benefits: (https://www.wpshealthsolutions.com/careers/fulltime_benefits.shtml)
  
  

Who We Are

WPS Health Solutions is a leading not-for-profit health insurer and federal government contractor headquartered in Wisconsin. WPS offers health insurance plans for individuals, families, seniors, and group health plans for small to large businesses. We process claims and provide customer support for beneficiaries of the Medicare program and manage benefits for millions of active-duty and retired military personnel across the U.S. and abroad. WPS Health Solutions has been making health care easier for the people we serve for more than 75 years. Proud to be military and veteran ready.

Culture Drives Our Success

WPS’ Culture is where the great work and innovations of our people are seen, fueled, and rewarded. We accomplish this by creating an open and empowering employee experience. We recognize the benefits of employee engagement as an investment in our workforce—both current and future—to effectively seek, leverage, and include differing and unique perspectives that fuel agility and innovation on high-performing teams. This results in people bringing their authentic selves to work every day in an organization that successfully adapts to business changes and new opportunities.

We are proud of the recognition we have received from local and national organization regarding our culture and workplace: WPS Newsroom - Awards and Recognition.

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