Grievance and Appeals Coordinator

POSITION SUMMARY 

The Grievance and Appeals Coordinator is responsible for the receipt, review, and triage of incoming correspondence related to member and provider grievances and appeals. This role focuses exclusively on intake functions, including mail handling, case creation, and accurate classification of cases within the system. The coordinator ensures all submissions are properly documented and routed in compliance with CMS, NCQA, and AHCA guidelines. This position does not perform case investigation or resolution.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to:

Key Responsibilities:

Mail Intake & Correspondence Handling

• Receive, open, sort, and review incoming correspondence (mail, fax, email, and electronic submissions) related to grievances and appeals. 
• Date-stamp and log all incoming documents in accordance with regulatory and organizational requirements. 
• Identify relevant documents and ensure they are complete and legible for processing. 

Case Creation & Data Entry

• Accurately create grievance and appeal cases in the organization’s case management system based on incoming correspondence. 
• Enter all required data elements, including member information, provider details, dates, and issue summaries. 
• Attach and index all supporting documentation to the appropriate case record. 
• Ensure data accuracy and completeness to support downstream processing. 

Triage & Classification

• Review correspondence to determine whether the request qualifies as a grievance or an appeal. 
• Categorize cases in alignment with CMS and NCQA guidelines (e.g., standard vs. expedited, pre-service vs. post-service). 
• Identify potential expedited or urgent requests and flag for immediate routing per established procedures. 
• Route cases to the appropriate team or queue for further handling. 

Regulatory Compliance

• Adhere to Centers for Medicare & Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), and Florida Agency for Health Care Administration (AHCA) guidelines for intake and case logging. 
• Ensure all cases are entered and routed within required regulatory timeframes. 
• Maintain audit-ready documentation and follow all internal policies and procedures. 

Claims & Denial Awareness

• Utilize basic knowledge of claim denials to support accurate identification and classification of appeal types. 
• Recognize common denial reasons to assist with proper case setup and routing.

Quality & Documentation

• Maintain accurate and detailed system notes related to intake activities. 
• Perform quality checks to ensure all required fields and documentation are completed at intake. 
• Support internal audits and quality reviews by ensuring consistency and compliance in case-entry. 

Collaboration

• Work closely with Grievance & Appeals processing teams, Claims, and other departments to ensure proper case routing. 

QUALIFICATIONS AND EDUCATION

Minimum Qualifications 

• High school diploma or equivalent required; associate or bachelor’s degree preferred. 
• Minimum of 1–3 years of experience in healthcare administration, managed care, claims, or intake processing. 
• Experience with mailroom operations, data entry, or case intake preferred. 

Preferred Qualifications 

• Experience in a Medicare or Medicaid managed care environment. 
• Prior intake or document processing experience in a regulated healthcare setting.

Skills & Competencies

• Basic understanding of healthcare claims and denial terminology. 
• Familiarity with CMS, NCQA, and AHCA guidelines related to grievances and appeals intake. 
• Strong data entry skills with high attention to detail and accuracy. 
• Ability to review and interpret documents quickly and accurately. 
• Strong organizational and time management skills. 
• Ability to meet strict turnaround and logging deadlines. 
• Proficiency in case management systems and standard office software. 

WORKING CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

PERFORMANCE MEASUREMENTS

This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

Employee Acknowledgement:

 
I have read this job description and understand what is expected of me while I occupy this role.

Salary : $19 - $21