Senior Appeals & Grievances Coordinator

MJHS; New York (NY); On-site; USD 45,000 - 65,000; Full time

Job summary

MJHS seeks an Appeals & Grievances Coordinator to manage non-clinical aspects of member and provider appeals and grievances, ensuring accurate intake, validation, and timely processing in compliance with CMS, DOH, and Elderplan policies.

The role includes case setup, triage, documentation, and coordination with clinical and operational teams to uphold high standards of accuracy and regulatory adherence.

Qualifications

• Associates Degree required; BA/BS Degree preferred.
• Minimum 2 years A&G or Member Service experience required.
• Knowledge of Medicare or Medicaid.
• Review newly created cases to confirm accurate classification or reassignment as necessary.
• Maintain regulatory compliance and company policy through thoughtful management of assigned caseload.

Responsibilities

• Review newly created cases to confirm accurate classification or reassignment to correct classification as necessary.
• Review history and identify additional information that may be required as part of the investigation.
• Respond in a timely manner to written and/or verbal appeals and grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations.
• Documents all relevant information in the Appeals and Grievances determination process within the appropriate designated areas of the A/G system.
• Maintain regulatory compliance and company policy through thoughtful management of assigned caseload.
• Presents cases to the Appeals & Grievances File Review Team as needed.
• Successfully complies with the accuracy of case files in key performance indicators during monitoring and auditing activities (95% of audited case files).
• Meet or exceed timeliness standards for all assigned cases

Skills

Communication

Documentation

Regulatory adherence

Caseload management

Timeliness

Education

Associates degree

BA/BS degree preferred

Job description

MJHS seeks an Appeals & Grievances Coordinator to manage non-clinical aspects of member and provider appeals and grievances, ensuring accurate intake, validation, and timely processing in compliance with CMS, DOH, and Elderplan policies.

The role includes case setup, triage, documentation, and coordination with clinical and operational teams to uphold high standards of accuracy and regulatory adherence.