Appeals and Grievances Coordinator 2

Overview

Manages all non-clinical aspects of member and provider appeals and grievances to ensure accurate intake, validation, timely case processing, and compliance with federal, state, and internal policy requirements. This role performs case setup, triage, documentation tracking, letter drafting, correspondence management, and coordination with clinical and operational teams. The coordinator supports member advocacy by ensuring each case proceeds through the proper workflow with a high degree of accuracy, professionalism, and regulatory adherence.

The MJHS Difference

At MJHS, we are more than a workplace; we are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services. We foster collaboration, celebrate achievements, and promote fairness for all. Our contributions are recognized with comprehensive compensation and benefits, career development, and the opportunity for a healthy work-life balance, advancement within our organization and the fulfillment of having a lasting impact on the communities we serve.

Benefits include:

• Tuition Reimbursement for all full and part-time staff
• Generous paid time off, including your birthday!
• Affordable and comprehensive medical, dental and vision coverage for employee and family members
• Two retirement plans! 403(b) AND Employer Paid Pension
• Flexible spending
• And MORE!

MJHS companies are qualified employers under the Federal Government’s Paid Student Loan Forgiveness Program (PSLF)

Responsibilities

• Review newly created cases to confirm accurate classification or reassignment to correct classification as necessary.

• Review history and identify additional information that may be required as part of the investigation.

• Respond in a timely manner to written and/or verbal appeals and grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations.

• Documents all relevant information in the Appeals and Grievances determination process within the appropriate designated areas of the A/G system.

• Maintain regulatory compliance and company policy through thoughtful management of assigned caseload.

• Presents cases to the Appeals & Grievances File Review Team as needed.

• Successfully complies with the accuracy of case files in key performance indicators during monitoring and auditing activities (95% of audited case files)

• Meet or exceed timeliness standards for all assigned cases

Qualifications

• Associates Degree required. BA/BS Degree preferred
• Minimum 2 years A&G or Member Service experience required 
• Knowledge of Medicare or Medicaid 

Min

USD $58,000.00/Yr.
Max

USD $65,000.00/Yr.