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About the Role
Manages non-clinical aspects of member and provider appeals and grievances, ensuring accurate intake, validation, timely processing, and compliance with regulations. This role supports member advocacy through accurate and professional case management.
Responsibilities
- Review newly created cases to confirm accurate classification or reassignment.
- Review case history and identify required additional information for investigation.
- Respond timely to written and/or verbal appeals and grievances in accordance with relevant regulations.
- Document all relevant information in the Appeals and Grievances system.
- Maintain regulatory compliance and company policy through caseload management.
- Present cases to the Appeals & Grievances File Review Team as needed.
- Achieve 95% accuracy in case files during monitoring and auditing.
- Meet or exceed timeliness standards for all assigned cases.
Requirements
- Minimum 2 years A&G or Member Service experience required.
- Knowledge of Medicare or Medicaid.
Experience Level
- Minimum 2 years experience
Education Level
- Associates Degree required
- BA/BS Degree preferred
Salary/Compensations
- USD $58,000.00/Yr. - USD $65,000.00/Yr.
Benefits
- Tuition Reimbursement for all full and part-time staff
- Generous paid time off, including your birthday!
- Affordable and comprehensive medical, dental and vision coverage for employee and family members
- Two retirement plans: 403(b) AND Employer Paid Pension
- Flexible spending
- Qualified employer under the Federal Government’s Paid Student Loan Forgiveness Program (PSLF)
About the Company
- MJHS is a supportive community committed to excellence, respect, and providing high-quality, personalized health care services.
- We foster collaboration, celebrate achievements, and promote fairness for all.
- Our contributions are recognized with comprehensive compensation and benefits, career development, and the opportunity for a healthy work-life balance, advancement within our organization and the fulfillment of having a lasting impact on the communities we serve.