Coordinator, Appeals

An Appeals Coordinator is responsible for coordinating member appeals, grievances, and other case types on behalf of various regions.  Regions are required under Federal and State regulations to have consistent and timely processes in place for reviewing, investigating, and responding to members requests and/or concerns. These requests often contain complex, confidential, and sensitive issues. The responsibility of this position is to ensure that all case types are carefully documented, thoroughly researched, and formally reviewed with decisions disseminated within timeframes established by the Region and/or by external regulators. The appeals and grievances processes represent an increasingly important aspect of the overall member, patient, and customer service/experience function of the organization.

• Documents the receipt of appeals (and other various case types, including grievances) and begins timeline tracking to ensure responses are generated within the established timeframe.


• Thoroughly researches and investigates each request/issue, including determining what information is necessary for an accurate and through review (e.g. medical records, emergency room reports, outside physician/hospital records, out-of-system records, and/or referral records) and takes appropriate steps to obtain that information. Uses knowledge and judgment to review, evaluate and summarize the information in a succinct and logical manner.  


• Ensures that eligibility information and benefit levels of members are determined, and ascertains if special/additional appeal and/or grievance mechanisms apply (e.g. Federal Group, Medicare) so that accurate and timely information can be included in member responses.


• Responsible for understanding health plan operations, including but not limited to:  Benefits, Grievances, Appeals, Authorizations, Referrals, Billings, and Claims.  Consults with other departments and stakeholders, as necessary, including Claims, QRM, Member Services, Risk Management, Medical Records, Medical Facilities, and Accounting, ensuring departmental responses meet various regulatory and departmental timelines.


• Prepares and distributes electronic Case Summaries for review and presentation to various internal stakeholders, normally in advance of Committee meetings and/or on an Ad-Hoc basis as required.


• Prepares various pieces of written correspondence for distribution internally, as well as externally.   


• Creates and Maintains member cases within the METRS system of record, following departmental DLPs and SOPs, to include case set up, leveling, identification of issue categories, and subcategories. Responsible for managing individual case inventories (and various other case processing standards), while maintaining regulatory compliance with established SLAs.   


• Prepares thoughtfully written professional responses to various stakeholders, including for External Review, as appropriate.