Medicare Appeals & Grievances Specialist

GuideWell; Florida; On-site; USD 28,000 - 34,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

Life insurance

Disability benefits

Retirement Savings Plan

Paid time off

Job summary

GuideWell seeks a Medicare Appeals and Grievances Coordinator to resolve member and provider appeals in compliance with CMS rules. You will manage case inventories, obtain medical records, track notifications, and coordinate with vendors to ensure timely determinations.

The role requires 3+ years in EM&B or Medicare, strong organization, and ability to work with cross‑functional teams. Florida location with comprehensive benefits and regular performance reviews.

Qualifications

• 3+ years related work experience in EM&B, Claims or Medicare.
• Experience with CMS regulatory guidelines and timeframes.
• Ability to work independently and collaboratively in a team.

Responsibilities

• Review appeal and grievance cases from various appellant types per CMS guidelines.
• Classify cases correctly and assess expedited requests.
• Resolves standard or expedited grievances and disputes involving reimbursement or medical necessity.
• Coordinate with internal partners and vendors to obtain medical records and data.
• Ensure CMS timeframes and written notifications are met.
• Document resolution steps and outreach to providers and members.
• Escalate issues as needed to management.

Skills

Medicare experience

EM&B experience

Analytical skills

Time management

Education

Bachelor's degree

High school diploma or GED

Tools

Siebel

Diamond

JIVA

ProviderConnect

Client Letter

ERCMS RADMD

Magellan

Blue 2

Job description

GuideWell seeks a Medicare Appeals and Grievances Coordinator to resolve member and provider appeals in compliance with CMS rules. You will manage case inventories, obtain medical records, track notifications, and coordinate with vendors to ensure timely determinations.

The role requires 3+ years in EM&B or Medicare, strong organization, and ability to work with cross‑functional teams. Florida location with comprehensive benefits and regular performance reviews.