Appeals Coordinator Nurse

Performs clinical reviews and resolves provider appeals, member appeals, grievances, corrected claims, inquiries, and reconsideration requests. Analyze, research, process, resolve, and respond to provider appeals, member appeals, grievances, corrected claims, reconsiderations, and customer inquiries.

Med Appeals and Grievance Specialist Coordinator


Job Summary

Performs clinical reviews and resolves provider appeals, member appeals, grievances, corrected claims, inquiries, and reconsideration requests. Reviews medical records, applies medical necessity criteria and benefit requirements, researches applicable policies, and communicates resolutions to customers and stakeholders.

Responsibilities

• Analyze, research, process, resolve, and respond to provider appeals, member appeals, grievances, corrected claims, reconsiderations, and customer inquiries.
• Review medical records and apply medical necessity criteria, benefit plan requirements, policies, procedures, provider contracts, fee schedules, and clinical guidelines.
• Respond to high-volume appeal and grievance correspondence through written and verbal communication.
• Maintain complete and accurate records in accordance with departmental policies and regulatory requirements.
• Meet quality, productivity, accuracy, and timeliness standards.
• Consult and coordinate with internal departments, external plans, providers, businesses, and government agencies to obtain information and resolve inquiries.
• Research claims, communications, eligibility, precertification, benefits, and coverage information.
• Explain contract benefits, coverage changes, eligibility, claims, programs, and provider network information to customers.
• Attend staff and interdepartmental meetings.
• Participate in continuing education and remain current on medical and managed care developments.
• Maintain compliance with applicable state, federal, regulatory, and accreditation requirements.
• Acquire specialized knowledge to process Level I appeals, grievances, and corrected claims across applicable lines of business.

Requirements

• At least one year of experience in a clinical, health insurance, or related healthcare field.
• Advanced clinical knowledge.
• Working knowledge of CPT, ICD-9, ICD-10, HCPCS, and DRG coding preferred.
• Working knowledge of clinical criteria and medical coverage guidelines preferred.
• Ability to interpret contract language and benefit plans preferred.
• Ability to maintain confidentiality and protect privacy.
• Strong investigative, analytical, research, problem-solving, and decision-making skills.
• Ability to interpret and communicate policies, procedures, programs, and guidelines.
• Strong written and verbal communication skills, including the ability to compose business correspondence.
• Ability to use office equipment and navigate multiple computer applications.
• Ability to enter, maintain, and retrieve accurate data records.
• Strong organizational skills with the ability to prioritize multiple tasks under time constraints.
• Ability to follow instructions, work independently, and collaborate effectively with others.
• Three years of experience in a clinical, health insurance, or related healthcare field preferred.

Skill

• Intermediate computer proficiency.
• Proficiency with office equipment, including copiers, scanners, fax machines, and telephones.
• Clinical review and medical necessity assessment.
• Health insurance appeals, grievances, claims, and reconsideration processing.
• Medical records analysis and benefits interpretation.
• Investigative research and analytical problem solving.
• Written and verbal communication.
• Active listening and customer service.
• Data entry and record maintenance across multiple systems.
• Time management, organization, and prioritization.
• Confidentiality and privacy compliance.

Summary Qualification

• Healthcare or health insurance experience with the ability to perform Level I appeals and grievance reviews.
• Strong understanding of clinical documentation, medical necessity criteria, benefit plans, and claims processes.
• Ability to manage high-volume work while maintaining accuracy, productivity, and regulatory compliance.
• Effective communicator capable of explaining complex healthcare and benefit information clearly.
• Demonstrated ability to work independently, exercise sound judgment, and collaborate with multiple stakeholders.

Wollborg Michelson Recruiting is an Equal Opportunity Employer and prohibits discrimination of any kind. We ensure job offers are made based of one s employment experience, skills, and qualifications, regardless of race, gender, ethnic origin, or any other classification protected by law. All applicants must furnish proper identification to prove their legal right to work in the US upon a job offer. We participate in E-Verify to confirm one s right to work in the US. Wollborg Michelson Recruiting does not provide sponsorship for an employment-based visa status.