Appeals and Grievances Coordinator

📋 Description

• • Serve as the primary point of contact for members, providers, and clients throughout the appeals and grievances process for dental and vision waiver services.
• • Review, analyze, and adjudicate member and provider appeals and grievances from all states, ensuring compliance with Avesis policy, plan documents, and applicable state and federal regulations.
• • Evaluate medical records, supporting documentation, and clinical guidelines to determine coverage decisions and issue administrative denials when appropriate.
• • Refer denials based on medical necessity to clinical staff for further review and decision-making.
• • Draft and issue formal correspondence including acknowledgement notices, resolution letters, and adverse determination letters in alignment with regulatory and organizational standards.
• • Collaborate with Claims, Provider Relations, Customer Service, and Clinical teams to resolve complex cases and ensure timely, accurate outcomes.
• • Prepare and submit all necessary documentation for Independent External Review when required by regulation.
• • Maintain strict adherence to regulatory timeframes for processing both member and provider appeals and grievances.
• • Apply knowledge of dental and vision benefit structures, CDT/CPT coding, and claims adjudication principles to assess coverage determinations accurately.
• • Ensure all case documentation is thorough, accurate, and compliant with HIPAA, NCQA, URAC, and Medicaid/Medicare regulations.
• • Participate in ongoing training to maintain and enhance functional expertise in appeals and grievances processes.
• • Contribute to team onboarding and knowledge sharing as experience grows, supporting peer development and operational consistency.
• • Demonstrate member-focused behavior by ensuring communication is clear, compassionate, and respectful, making members feel seen and valued.
• • Maintain exceptional time management skills to prioritize competing deadlines and manage a high-volume caseload while ensuring regulatory compliance.
• • Work independently with minimal supervision while also collaborating effectively across departments to achieve shared goals.
• • Demonstrate critical thinking and problem-solving skills to troubleshoot complex cases involving conflicting guidelines or ambiguous policy interpretations.
• • Maintain confidentiality and integrity when handling protected health information and sensitive member data.
• • Remain flexible and responsive to changing regulatory requirements, internal policy updates, and evolving operational demands.
• • Perform Saturday shifts on an alternating basis during holiday periods as required to ensure continuous service delivery.
• • Utilize Microsoft Office Suite and healthcare administrative systems to document case outcomes, track timelines, and maintain case records with precision.
• • Support audit readiness by ensuring all documentation is complete, accurate, and organized for internal and external reviews.