Appeals and Grievances Coordinator

🔥 7 minutes ago

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Avēsis

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1978

⚕️ Healthcare Insurance

🧘 Wellness

Healthcare Insurance • Wellness

Avēsis is a company dedicated to providing comprehensive specialty benefits focused on improving access, equity, and health outcomes. Specializing in dental and vision plans, Avēsis offers flexible, affordable, and outcome-focused oral health benefits as well as vision plans that connect eye health to overall well-being. With over 40 years of experience, Avēsis is committed to personalized care and building community health networks to service government partners, commercial providers, employers, and brokers. Avēsis operates as a wholly owned subsidiary of Guardian, and leverages tailored network and product solutions to deliver accessible quality care to members, while also administering Medicaid, Medicare, and other essential benefits programs.

📋 Description

• The Appeals and Grievances Coordinator is the primary point of contact for members, providers, and clients throughout the appeals and grievances process. • Provide timely, accurate, and compliant resolution of dental and vision A&G cases within a regulated managed care environment. • 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. • Draft formal correspondence such as acknowledgement and resolution notices.

🎯 Requirements

• 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.

🏖️ Benefits

• 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.