Appeal and Grievance Coordinator Reviewer

Spectraforce Technologies

500 West Peace Street (Show on map)
Jul 15, 2026
Position Title: Appeal and Grievance Coordinator Reviewer Work Location: Remote Role Assignment Duration: 4+ Months Work Arrangement: Remote Position Summary: * Performing research and processing of appeals, grievances, corrected claims, medical records and related correspondence in accordance with our organization, State, Federal and other accreditation requirements as applicable. Key Responsibilities: * Perform analysis and research of requests received for medical grievances, appeals for final resolution or referral to the Clinical Medical Appeals and Grievance (MAG) Staff. * Maintains advanced end user knowledge of multiple systems including vendor medical management and claims systems. * Conduct research to resolve requests received from members, providers and other Blue Plans in accordance with State, Federal, BlueCard and URAC timeliness standards. * Review medical records to determine if records satisfy the requested or supporting information required. * Complete specific Appeals and Grievances after clinical training. * Maintain current medical terminology knowledge. * Identify research and assemble medical records, coverage guidelines, claims and historical data for MAG staff review and presentation to the Medical Director, Department of Insurance, Executive Inquiries or other legal proceedings. * Perform data corrections and initiate adjustments related to appeals originating from the Medical Grievance and Appeals Department. Communicate decisions through appropriate system updates. * Analyze and monitor appeals, grievances, and insufficient records to identify possible trends or patterns and document and report findings to Supervisor and/or Manager with suggestions and follow-up. * Assist in utilization studies and analysis. * Meet department and individual contributor goals. * Performs activities with limited supervision. * Use pharmacy system to research and prepare level 2 and external pharmacy cases. * Monitor proxy box for pharmacy appeals and grievances. * Monitors Appeals and Grievance Coordination (AGC) proxy boxes and phones as assigned. * Demonstrates commitment to excellent customer experience. * Maintain understanding and working knowledge of a variety of lines of business including fully insured, self-funded groups, Affordable Care Act individuals and groups, and Blue Card. * Maintain understanding of Medical Management and claims processing systems. * Process records/document requests related to appeals and grievances. * Works with vendors and special groups to ensure appropriate communication between levels of appeals including sending required documentation to group/vendor contact. * Researches and reopens claims appeals for diagnosis mismatch. * Researches and communicates with legal team as directed by leadership, including assisting with written communication. * Attest to training competency related to medical terminology and new/revised processes. * Ensure HIPAA compliance/PHI privacy. * Communicates with privacy office as indicated related to CMS1557 discrimination grievance requests. * Assists with research and preparation of appeals files for accreditation site visits. * Completes mandatory training and 3 or more additional training courses. * Completes IDP and participates in Perceptyx action plan. * Maintain current knowledge and understanding of State, Federal, our organization, Blue Card, and accreditation requirements as applicable, pertaining to appeal and grievance timeframes, processing, tracking, analysis and reporting to ensure case reviews are completed accurately and timely. * Other duties as assigned. Qualification & Experience: * 1 years of experience in claims processing, medical/pharmacy precertification, appeals and grievances coordination or other applicable related work experience * High-School Diploma or higher. * Intermediate PC proficiency. * Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones. * Intermediate skill in word processing, spreadsheet and database software. * Intermediate written communication and letter writing skills. * Ability to perform investigative and analytical research. * Establish and maintain working relationships in a collaborative team environment. * Practice interpersonal and active listening to achieve high customer satisfaction and departmental communication standards. * Interpret and translate policies, procedures, programs and guidelines.