Medicare Appeals & Grievances Specialist (Hybrid)

Florida Blue Group; Jacksonville (FL); Hybrid; USD 28,000 - 45,000; Full time

Benefits offered by this job

Medical, dental, vision, life and glob

Travel health insurance

Retirement savings plan with employer"

Job summary

Florida Blue Group seeks an Appeals and Grievances Coordinator to resolve member and provider appeals with adherence to regulatory timelines. The role includes data gathering, working with vendors, and documenting resolutions across multiple systems in a hybrid work setup.

The candidate should have 3+ years of relevant experience, a high school diploma or GED (Bachelor's preferred), and strong Medicare knowledge. Excellent interpersonal, analytical, and detail-oriented skills are essential.

Qualifications

• 3+ years related work experience in appeals/grievances.
• High school diploma or GED required.
• Experience with Siebel, Diamond, JIVA and Medicare databases.
• Ability to work flexible schedule including overtime and weekends.
• Medicare product knowledge is required.
• Ability to work independently and as part of a team.
• Strong interpersonal, analytical and detail-oriented skills.

Responsibilities

• Review appeal and grievance cases from member, representative, physician and non-participating providers.
• Resolve complex standard or expedited grievances in accordance with guidelines.
• Prioritize case workload to meet timeframes and notifications.
• Access systems to gather data and document resolutions.
• Document research details and actions taken for resolution.
• Coordinate with internal partners and gather required data or medical records.
• Ensure proper research and final determinations with timely notifications.
• Outreach to members, providers and partners to close resolutions.
• Escalate calls and issues to Manager as needed.

Skills

Medicare product knowledge

Interpersonal skills

Analytical problem-solving

Attention to detail

Independent and collaborative work

Ability to manage multiple priorities

Flexible schedule including overtime &

Education

High school diploma or GED

Bachelor’s degree

Tools

Siebel

Diamond

JIVA

ProviderConnect

Client Letter

ERCMS RADMD

Magellan

Blue 2

Job description

Florida Blue Group seeks an Appeals and Grievances Coordinator to resolve member and provider appeals with adherence to regulatory timelines. The role includes data gathering, working with vendors, and documenting resolutions across multiple systems in a hybrid work setup.

The candidate should have 3+ years of relevant experience, a high school diploma or GED (Bachelor's preferred), and strong Medicare knowledge. Excellent interpersonal, analytical, and detail-oriented skills are essential.