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Appeals & Grievances Coordinator

Nirvana Health Inc

MA

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JOB DETAILS
SKILLS
Administrative Skills, Artificial Intelligence (AI), Automation, Case Management, Centers for Medicare and Medicaid Services (CMS), Cloud Computing, Code of Federal Regulations, Communication Skills, Content Management Systems (CMS), Cross-Functional, Customer Escalations, Customer Support/Service, Data Collection, External Audit, HIPAA (Health Insurance Portability and Accountability Act), Healthcare, Machine Learning, Maintain Compliance, Medicaid, Medicare, Microsoft Excel, Microsoft Office, Microsoft Outlook, Microsoft Windows Operating System, Microsoft Word, National Committee for Quality Assurance (NCQA), Operational Support, Organizational Skills, Pharmacy, Presentation/Verbal Skills, Quality Assurance, Quality Management, Regulations, Regulatory Reports, Standard Operating Procedures (SOP), Trend Analysis, Utilization Management, Utilization Review Accreditation Commission (URAC), Writing Skills
LOCATION
MA
POSTED
30 days ago

Job Summary

nirvanaHealth is rebuilding the payer enterprise on a digital workforce. Our cloud-native Aria platform delivers payer administrative and care-continuum functions as Transaction-as-a-Service (TaaS) - combining robotic process automation, machine learning, and agentic AI to execute the thousands of transactional functions that currently consume payer operating margin. We operate across Medicare Advantage, Medicaid, Commercial, ASO, and ACA lines of business.

As an Appeals & Grievances (A&G) Coordinator, you will help support the intake, review, and resolution of member and provider appeals and grievances while ensuring cases are handled accurately, compliantly, and within CMS-mandated timelines. In this role, you will work closely with the VP of Health Services and partner across clinical, compliance, operations, and customer service teams while using Aria's A&G module and emerging AI-assisted workflows to support member rights and deliver audit-ready outcomes. This position also supports delegated operations, requiring adaptability across process variations while maintaining consistent regulatory compliance.

Job Responsibilities

  • Manage cases end-to-end - Receive, document, investigate, and resolve member and provider appeals (Part C and Part D) and grievances submitted via phone, fax, email, mail, or portal. Track and enforce CMS timeliness.
  • Draft member-facing communications - Draft acknowledgment and resolution letters that are clear, empathetic, and fully compliant with CMS, state, and accreditation (NCQA/URAC) requirements.
  • Collaborate cross-functionally - Partner with Medical Directors, Compliance, Pharmacy, Utilization Management, Customer Service, and external review bodies to build complete case folders and drive meaningful outcomes.
  • Support delegated operations - Execute A&G processes across delegated environments, maintaining process variations where needed while adhering to standard operating procedures.
  • Prepare evidence for external review - Compile and organize case files for IRE auto-forwards and external audit bodies.
  • Leverage emerging tools - In addition to MS Office and other Windows-based tools, utilize emerging tools to drive quality and productivity.
  • Surface insights and support reporting - Compile data for regulatory reporting, help identify trends, and contribute to quality improvement initiatives.

Qualifications

Category

Required

Preferred

Education

  • Bachelor's degree or equivalent experience

Experience

1-3 years of related experience

Hands-on A&G case management, prior auth, or compliance/quality experience; Medicare Advantage, Medicaid, or Commercial plan environment

Regulatory Knowledge

Working familiarity with CMS guidance, Medicare Part C & D regulations, member rights under 42 CFR §§422/423

NCQA and/or URAC accreditation standards; Massachusetts state requirements (MassHealth, DOI, Office of Patient Protection)

Writing & Communication

Strong professional writing skills - you will draft acknowledgment, resolution, and determination letters daily; effective verbal communication with members, providers, clinical staff, and external agencies

  • Tools & Technology

Microsoft Office (Excel, Word, Outlook); comfort with case management and tracking systems

Healthcare payer platform experience

Core Competencies

Detail orientation under regulatory deadlines; critical thinking in case investigation; high-volume caseload management; de-escalation & customer service orientation; HIPAA/PHI compliance

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About the Company

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Nirvana Health Inc