Grievance & Appeals Operations Lead

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 seeks a Grievance and Appeals Coordinator to manage intake, routing, and timely resolution of Medicaid, Medicare, and commercial grievances, appeals, and complaints. The role supports GAU operations by assigning cases, generating initial acknowledgments, and maintaining accurate, secure records and documentation.

The coordinator collaborates with internal departments to ensure compliance with CMS, OHIC, and Medicaid rules, prepares routine and ad-hoc

Qualifications

• Associates degree or equivalent work experience.
• Ability to identify problems and irregularities, collect data, and draw conclusions.
• Basic knowledge of medical terminology and CPT/ICD-9/10 coding.
• Basic knowledge of state and federal laws and resources.
• Strong prioritization and time management skills.
• Excellent customer service orientation and phone etiquette.
• Strong interpersonal skills.
• Proficient in Microsoft Office applications (Excel, Word, PowerPoint, Outlook).
• Experience with healthcare management systems and ability to use proprietary systems.

Responsibilities

• Manage intake of Medicaid, Medicare and Commercial grievances, appeals, and complaints.
• Scan and convert paper grievances to electronic format for processing.
• Generate timely initial member acknowledgments (verbal or written).
• Track grievances, appeals and complaints electronically and attach to member records.
• Intake, process, and monitor external appeals for Medicaid and commercial products.
• Ensure compliance and timely resolution letters.
• Quality-check member/provider letters; obtain legal input when needed.
• Collaborate across departments to respond to inquiries and maintain timelines.

Skills

Analytical thinking

Problem solving

Medical terminology

Regulatory knowledge

Time management

Customer service

Interpersonal skills

Microsoft Office

Healthcare IT systems

Proprietary HMS systems

CPC certification

Claims processing

Business writing

Education

Associates degree or relevant experience

Business-related degree (preferred)

Tools

Microsoft Office

Proprietary healthcare system

Healthcare management systems

Job description

Neighborhood Health Plan of Rhode Island seeks a Grievance and Appeals Coordinator to manage intake, routing, and timely resolution of Medicaid, Medicare, and commercial grievances, appeals, and complaints. The role supports GAU operations by assigning cases, generating initial acknowledgments, and maintaining accurate, secure records and documentation.

The coordinator collaborates with internal departments to ensure compliance with CMS, OHIC, and Medicaid rules, prepares routine and ad-hoc