Grievance and Appeals Coordinator

The Grievance and Appeals Coordinator is responsible for supporting the Grievance and Appeals Unit (GAU) by managing intake, assignment, and tracking of appeals and complaints/grievances across all product lines. This role ensures timely and compliant correspondence to members and providers, monitors case progress, and alerts staff when deadlines approach. The Coordinator also manages the external appeals processes, ensuring agencies meet resolution timeliness and cases are assigned according to rotation protocols.

The Coordinator maintains organized and secure record-keeping systems, communicates effectively with internal and external stakeholders, and fosters collaborative relationships across departments to ensure compliance and exceptional service.

Duties and Responsibilities:

Duties include but are not limited to:

Intake and process all Medicaid, Medicare, and Commercial appeals, grievances, and complaints including potential Quality of Care issues.

Scan and convert paper submissions into electronic format for departmental processing.

Generate timely and compliant acknowledgement letters (verbal and/or written).Track and monitor all cases electronically, ensuring accurate documentation and timely updates

Manage external appeals for Medicaid and Commercial lines, including assignment and compliance monitoring.

Follow up with internal departments and delegated entities to ensure resolution within required time frames.

Monitoring and oversight over GAU required forms, including review with the legal department for appropriateness.

Provide training to new team members as needed.

Maintain compliance with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, and all applicable laws and regulations/Perform other duties as assigned.

Other duties as assigned

Qualifications

Required:

Associates degree or equivalent work experience.

Strong analytical skills with ability to identify issues, collect data, and draw valid conclusions.

Basic knowledge of medical terminology and CPT and ICD
10 coding.

Familiarity with state and federal laws related to grievances and appeals.

Excellent organizational, prioritization, and time management skills.

Strong customer service orientation and professional communication skills.

Proficient in Microsoft Office (Excel, Word, PowerPoint, Outlook).

Experience with Healthcare management systems and ability to learn proprietary platforms.

Flexibility to work evenings/weekends as needed.

Preferred:

Associate’s degree in business-related field2+ years of experience in healthcare or health insurance.

Knowledge of Medicare and Medicaid benefits and requirements.

Familiarity with CMS, OHIC, and EOHHS regulations related to grievances and appeals

Experience communicating with provider networks.

Certified Professional Coder (CPC) credentials.

Experience with claims adjudication systems.

Strong business writing skills for member and provider communications.

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
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