Medicare Appeals & Grievances Specialist

GuideWell; Jacksonville (FL); Hybrid; USD 28,000 - 45,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

Life insurance

Disability benefits

Retirement plan with employer match

Paid time off

Holidays and well-being days

Job summary

GuideWell is seeking an Appeals and Grievances Coordinator in Jacksonville, FL to resolve member appeals and grievances in compliance with regulatory timeframes. The role emphasizes SLA-driven prioritization, data gathering across multiple systems, and collaboration with providers and vendors to obtain medical records.

The position requires 3+ years in EM&B, Claims, or Medicare with strong interpersonal and analytical skills, plus familiarity with Siebel, Diamond, JIVA, and related tools.

Qualifications

• 3+ years related work experience in EM&B, Claims or Medicare

Responsibilities

• Review appeal and grievance cases from member, representative, physician, and non-participating providers in line with guidelines and timeframes
• Resolve complex standard or expedited grievances, appeals or disputes regarding reimbursement, medical necessity and benefits
• Prioritize case workload to meet timeframes and notifications
• Access systems such as MAAGC, JIVA, Diamond, Siebel, ProviderConnect, Client Letter, ERCMS RADMD, Magellan, and Blue 2 to gather data
• Document resolution with supporting details and attach relevant documents
• Coordinate with internal partners and gather data or medical records for clinical decisions and delegated vendors
• Ensure research is documented to render final determinations with notifications to appellants within timeframes
• Outreach to members, providers, and partners to complete resolution of appeals/grievances
• Escalate issues or calls to Manager as needed

Skills

Interpersonal skills

Analytical skills

Multitasking

Problem-solving

Medicare knowledge

Education

High school diploma or GED

Bachelor’s degree

Tools

Siebel

Diamond

JIVA

ProviderConnect

Client Letter

ERCMS RADMD

Magellan

Blue 2

Job description

GuideWell is seeking an Appeals and Grievances Coordinator in Jacksonville, FL to resolve member appeals and grievances in compliance with regulatory timeframes. The role emphasizes SLA-driven prioritization, data gathering across multiple systems, and collaboration with providers and vendors to obtain medical records.

The position requires 3+ years in EM&B, Claims, or Medicare with strong interpersonal and analytical skills, plus familiarity with Siebel, Diamond, JIVA, and related tools.