Appeals Coordinator

Accountabilities:: Maintain an assigned caseload and monitor compliance with appeal decision timelines and applicable procedures. Review clinical and medical records for completeness and determine whether cases require administrative or clinical appeal review. Coordinate and distribute first-, second-, and third-level appeal assignments to the appropriate reviewers. Assign cases requiring medical necessity review to physician advisers and medical directors. Enter accurate appeal and case review information into databases and maintain complete documentation. Prepare and present appeal information to panels and second-level multidisciplinary committees. Gather and analyze appeal activity data and support the preparation of internal and external appeals audits. Participate in quality improvement activities and contribute to the development and implementation of department workflows. Support training for new employees and help ensure team members understand applicable procedures and performance standards. Consult with managers and collaborate with case managers, clinical supervisors, account managers, and other personnel to resolve denial and appeal questions. Respond to member, provider, and client inquiries regarding appeal status, processes, and outcomes. Organize daily workloads and workflows to ensure appeals are resolved accurately, efficiently, and in accordance with client requirements and applicable regulations. Requirements: High school diploma or GED required; an associate degree is preferred. Previous customer service experience, particularly in roles involving direct customer interactions and detailed documentation. Experience with data entry and case management. Strong letter-writing, writing, proofreading, and document-review skills, with excellent attention to accuracy and detail. Proficiency with Microsoft Office and Microsoft Suite applications. Ability to review and understand health-related materials and handle sensitive information professionally. Strong interpersonal and communication skills, with the ability to interact effectively with members, providers, clients, and internal stakeholders. Highly organized and capable of managing multiple cases, priorities, and deadlines effectively. Ability to recognize when assistance is needed and seek appropriate support on complex or unfamiliar tasks. Experience in healthcare is a plus. Customer service experience is valued. Typing speed of approximately 50 words per minute is preferred. Benefits: Opportunity to contribute to healthcare appeal and case management operations. Exposure to clinical, administrative, and regulatory processes within a healthcare environment. Opportunities to collaborate with multidisciplinary teams and healthcare professionals. Experience supporting quality improvement, audits, reporting, and workflow initiatives. Professional development through employee training and involvement in departmental projects.