Appeals Coordinator Lead

Founded in 1999 and headquartered in Central Ohio, we’re a privately‑owned, independent healthcare navigation organization. We believe that no one should have to navigate the cost and complexity of healthcare alone, and we’re on a mission to make healthcare simpler and more effective for our millions of members. Our big‑hearted, tech‑savvy team fights to ensure that our members get the care they need, when they need it, at the most affordable cost – that’s why we call ourselves Healthcare Warriors®.

We’re committed to building diverse and inclusive teams – more than 2,000 of us and counting – so if you’re excited about this position, we encourage you to apply – even if your experience doesn’t match every requirement.

The Appeals Coordinator Lead serves as both a subject matter expert and team leader, responsible for guiding and coaching Appeals Coordinators while actively managing appeal requests. This role ensures compliance with Department of Labor guidelines, Summary Plan Description provisions, and internal processes. The Lead will balance leadership duties with hands‑on work, driving operational excellence and fostering team development.

Location: This position is located at our Dublin, OH campus with hybrid flexibility.

• Process Appeal Requests
• Intake appeal and document in Appeals System
• Review appeal requests and supporting documentation to determine disputed issues.
• Research Summary Plan Document provisions, claim notes, and collaborate with Third Party Administrator partners to validate denial reasons.
• Apply critical thinking and fact‑based decision‑making to render determinations.
• Draft and send outcome letters using approved templates; address member/provider concerns.
• Ensure timely processing to meet Summary Plan Description (SPD) and Department of Labor (DOL) requirements.
• Coordinate with Appeal Nurse and/or IRO for clinical reviews.
• Communicate outcomes with members, providers, facilities, and internal teams.

• Serve as the subject matter expert for appeal processes, workflows, and benefit plans.
• Coach and mentor Appeals Coordinators; provide feedback and support for skill development.
• Lead team huddles, monitor workload distribution, and assist with prioritization.
• Partner with management to identify training needs and deliver educational sessions.
• Act as an escalation point for complex or high‑profile appeals.

• Stay current on DOL guidelines, ACA requirements, and Federal External Appeal rights.
• Identify opportunities for workflow optimization and contribute to process improvement initiatives.
• Collaborate with Client Executives and Managers on escalated appeals and SPD interpretation.
• Support member experience teams with calls, special projects, and cross‑functional initiatives as needed.
• Other duties as assigned

• Strong knowledge of health insurance coverage, claims, and appeal processes with a minimum of 2 years of appeals experience required.
• Leadership and/or mentoring experience required.
• Excellent verbal and written communication skills; ability to coach and influence others.
• Critical thinking and independent judgment in decision‑making.
• Highly organized with strong time management skills; able to balance leadership and case work.
• Proficiency in Microsoft Office with the ability to quickly learn internal business systems.
• Knowledge of Department of Labor time frames, ACA, and SPD provisions.
• Protect and take care of our company and member’s data every day by committing to work within our company ethics and policies
• Strong administrative/technical skills;
  Comfort working on a PC using Microsoft Office (Outlook, Word, Excel, PowerPoint), IM/video conferencing (Teams & Zoom), and telephones efficiently.
• A high degree of personal accountability and trustworthiness, a commitment to working within Quantum Health’s policies, values and ethics, and to protecting the sensitive data entrusted to us.