Senior Coordinator, Complaints & Appeals Operations

• Process daily appeals for Commercial Member Clinical Appeals (CMCA)
• Complete appeals determination letters
• Intake and launch expedited requests
• Provide verbal expedited notifications and determinations
• Update systems and complete reporting as necessary
• Support the panel hearing process
• Collaborate with clinical support staff, including Medical Directors, Nurses, and Providers
• Triage faxes
• Move cases through the Complaints and Appeals Tracking System (CATS)
• Handle work in compliance with turnaround times and regulatory standards

• Familiar with Medical Terminology
• Strong written and verbal communication
• Ability to multi-task
• Proficient in basic computer skills including Microsoft Office Suite
• High School Diploma

Demonstrates proficiency in processing clinical appeals and managing expedited requests while ensuring compliance with regulatory standards. Strong communication skills are essential for collaboration with clinical support staff and for drafting determination letters.

• Medical Terminology
• Written Communication
• Verbal Communication
• Microsoft Office Suite
• Compliance with Regulatory Standards

• Appeals Processing
• Determination Letters
• Expedited Requests
• Reporting
• Complaints and Appeals Tracking System

• Multi-tasking
• Collaboration

• High School Diploma

• Clinical Appeals
• Regulatory Standards
• Clinical Support Staff