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The Appeals and Grievances Coordinator is the primary point of contact for members, providers, and clients throughout the appeals and grievances process. Although this role will report to the Supervisor, Appeals and Grievances, this individual will receive day-to-day performance support and case guidance from the A&G Team Lead. You will, provide timely, accurate, and compliant resolution of dental and vision A&G cases within a regulated managed care environment. The coordinator collaborates with Claims, Provider Relations, Customer Service, and Clinical teams, and is expected to contribute to team onboarding and knowledge sharing as their experience grows.
Functional:
- Responsible for the completion of appeals and grievances from all states
- Perform reviews of member and provider appeals and grievances for dental and vision waiver services
- Analyze medical records, supporting documentation, and applicable guidelines to make informed decisions
- Document rationale clearly and accurately in alignment with organizational and regulatory standards
- Work closely with clinical teams as well as other internal operational areas to resolve complex cases.
- Communicate outcomes effectively to members and providers.
- Review and complete all provider appeals and grievances within required timeframes
- Review and complete member appeals and grievances within required timeframes
- Apply Avesis policy, plan documents and/or state guidelines when processing appeals or grievances
- Issue administrative denials appropriately
- Refer denials based on medical necessity to appropriate clinical staff
- Collaborate with appropriate stakeholders to prepare all requests for Independent External Review when required
- Participate in training programs to maintain functional expertise
- Perform any other job duties as requested
Core:
- Draft formal correspondence such as acknowledgement and resolution notices.
- Working knowledge of dental and vision benefit structures, CDT/CPT coding, and claims adjudication principles to evaluate coverage determinations
- Intermediate proficiency with Microsoft Office products
- Knowledge of NCQA, URAC and Medicaid regulations
- Ability to navigate complex regulations while maintaining a commitment to high-quality care
- Strong written and oral communication skills
- Ability to work independently and within a team environment
- Exceptional Time management skills to ensure regulatory compliance
- Decision making/problem solving skills
- Knowledge of Medicaid and Medicare
- Change resiliency
Behavioral:
- Collegiality: building strong relationships on company-wide, approachable, and helpful, ability to mentor and support team growth.
- Initiative: readiness to lead or take action to achieve goals.
- Communicative: ability to relay issues, concepts, and ideas to others easily orally and in writing.
- Member-focused: going above and beyond to make our members feel seen, valued, and appreciated.
- Detail-oriented and thorough: managing and completing details of assignments without too much oversight.
- Flexible and responsive: managing new demands, changes, and situations.
- Critical Thinking: effectively troubleshoot complex issues, problem solve and multi-task.
- Integrity & responsibility: acting with a clear sense of ownership for actions, decisions and to keep information confidential when required.
- Collaborative: ability to represent your own interests while being fair to those representing other or competing ideas in search of a workable solution for all parties.
Minimum Qualifications:
- High school diploma or equivalent.
- 1+ years of exposure with medical, dental or vision terminology and/or coding (ICD-10, CDT, CPT).
- 1+ years of experience with case management platforms or healthcare administrative systems
- Working knowledge of medical, dental, or vision terminology and coding (ICD-10, CDT, CPT) relevant to the line of business.
- Proficiency in Microsoft Office Suite and experience with case management platforms or healthcare administrative systems.
- Ability to draft formal correspondence.
- Demonstrated understanding of HIPAA and the ability to handle protected health information in a compliant manner.
- Proven ability to manage a high-volume caseload, prioritize competing deadlines, and meet strict regulatory turnaround time requirements.
- Strong attention to detail, critical thinking, and sound judgment with the ability to work both independently and collaboratively across departments.
- Flexible to work alternating Saturday during holiday shifts as required.
- As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 10 Mbps upload while hardwired and not on a VPN are sufficient.
Preferred Qualifications:
- 1+ years of experience drafting adverse determination letters, supporting audit readiness, or working in managed care A&G case management platforms.
- Familiarity with applicable federal and state regulations governing appeals and grievances, including 42 CFR Parts 422 and 438 and NCQA standards.
- Registered Dental Hygienist or Dental Assistant credential
At Avēsis, we strive to design equitable, and competitive compensation programs. Base pay within the range is ultimately determined by a candidate's skills, expertise, or experience. In the United States, we have three geographic pay zones. For this role, our current pay ranges for new hires in each zone are:
Zone A: $18.33-$30.55Zone B: $19.97-$33.29Zone C: $21.50-$35.84FLSA Status: Hourly/Non-Exempt
This role may also be eligible for benefits, bonuses, and commission.
Please visit Avesis Pay Zones for more information on which locations are included in each of our geographic pay zones. However, please confirm the zone for your specific location with your recruiter.
We Offer
- Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
- Competitive compensation package.
- Excellent medical, dental, supplemental health, life and vision coverage for you and your dependents with no wait period.
- Life and disability insurance.
- A great 401(k) with company match.
- Tuition assistance, paid parental leave and backup family care.
- Dynamic, modern work environments that promote collaboration and creativity to develop and empower talent.
- Flexible time off, dress code, and work location policies to balance your work and life in the ways that suit you best.
- Employee Resource Groups that advocate for inclusion and diversity in all that we do.
- Social responsibility in all aspects of our work. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.
How To Stay Safe
Avēsis is aware of fraudulent activity by individuals falsely representing themselves as Avēsis recruiters. In some instances, these individuals may even contact applicants with a job offer letter, ask applicants to make purchases (i.e., a laptop or gift cards) from a designated vendor, have applicants fill out W-2 forms, or ask that applicants ship or send packages of goods to the company.
Avēsis would never make such requests to applicants at any time throughout our job application process. We also would never ask applicants for personal information, such as passport numbers, bank account numbers, or social security numbers, during our process. Our recruitment process takes place by phone and via trusted business communication platform (i.e., Zoom, Webex, Microsoft Teams, etc.). Any emails from Avēsis recruiters will come from a verified email address ending in @ Avēsiscom.
We urge all applicants to exercise caution. If something feels off about your interactions, we encourage you to suspend or cease communications. If you are unsure of the legitimacy of a communication you have received, please reach out to ITsupport@Avesis.com.
To learn more about protecting yourself from fraudulent activity, please refer to this article link (https://consumer.ftc.gov/articles/how-avoid-scam). If you believe you were a victim of fraudulent activity, please contact your local authorities or file a complaint (Link: https://reportfraud.ftc.gov/#/) with the Federal Trade Commission. Avēsis is not responsible for any claims, losses, damages, or expenses resulting from unaffiliated individuals of the company or their fraudulent activity.
Equal Employment Opportunity
At Avēsis, We See You. We celebrate differences and are building a culture of inclusivity and diversity. We are proud to be an Equal Employment Opportunity employer that considers all qualified applicants and does not discriminate against any person based on ancestry, age, citizenship, color, creed, disability, familial status, gender, gender expression, gender identity, marital status, military or veteran status, national origin, race, religion, sexual orientation, or any other characteristic. At Avēsis, we believe that, to operate at the peak of excellence, our workforce needs to represent a rich mixture of diverse people, all focused on providing a world-class experience for our clients. We focus on recruiting, training and retaining those individuals that share similar goals. Come Dare to be Different at Avēsis, where We See You!
