Appeals and Grievances Coordinator

Join us for an exciting career with the leading provider of supplemental benefits!

Our Promise
Through skill-building, leadership development and philanthropic opportunities, we provide opportunities to build communities and grow your career, surrounded by diverse colleagues with high ethical standards.

The Appeals and Grievances Coordinator serves as the primary point of contact for members, providers and clients regarding their appeals and grievances, providing updates and ensuring clear communication throughout the process. In this role, the Appeals and Grievance Coordinator will collaborate with internal teams, including claims, provider relations, and customer service, to resolve issues effectively. The Appeals and Grievance Coordinator is accountable for the timely, accurate, compliant, and complete review and resolution of Medicaid Dental and Vision Appeals and Grievances Cases.

Competencies:

Functional:

• Manage the full appeals process, ensuring timely and effective resolutions.
• Speak to members and providers regarding details of cases and requests or next steps, with empathy and compassion.
• Analyze case details and make informed decisions based on regulatory requirements.
• Maintain accurate and organized records of all appeals and grievance cases.

• Utilize electronic health records and claims processing systems.
• Apply regulatory guidelines and compliance standards related to dental and vision services.

• Stay current with policy changes and effectively implement them.
• Ability to prioritize tasks to ensure compliance with turnaround time requirements.

• Proficient in analyzing data trends to identify issues and recommend improvements.

Core:

• Excellent verbal and written communication skills, with the ability to convey complex information clearly.
• Strong interpersonal skills to effectively interact with members and internal teams.
• Strong analytical and critical thinking skills to assess situations and develop effective solutions.
• Ability to manage multiple cases and priorities efficiently.
• High level of attention to detail in reviewing case information and documentation.
• Ability to identify discrepancies and ensure compliance.
• Ability to work collaboratively with cross-functional teams to achieve common goals.
• Strong relationship-building skills to foster a supportive work environment.

Behavioral:

• Collegiality: building strong relationships with internal and external clients and customers, approachable and helpful, ability to mentor and support team growth. 
• Initiative: readiness to lead or take action to achieve goals.
• Communicative: ability to communicate issues, concepts, and ideas effectively, both verbally and in writing.
• Member-focused: going above and beyond to make our members feel seen, valued, and appreciated.
• Detail-oriented and thorough: managing and completing details/documentation of case assignments with a risk-management mindset.
• Flexible and responsive: managing new demands, changes, and situations in a quality-centric manner.
• Critical Thinking: effectively troubleshoot complex issues, problem solve, and multitask.
• Integrity & responsibility: acting with a clear sense of accountability, maintaining the integrity of the organization, your work as well as the work you do on behalf of our clients, providers and enrollees.
• Collaborative: ability to represent departmental or individual interests and needs with a holistic, helpful, and collaborative approach.

Minimum Qualifications:

• High School Diploma or equivalent
• 2+ years of experience in appeals and grievances within the dental, vision, or insurance industry.
• Proficiency in Microsoft Office Suite and experience with claims processing systems.
• Must be flexible to work a Saturday shift if required.
• As this role is a remote role, you are required to maintain internet service that allows you to complete your essential job duties without issue. Rates of 50 Mbps download and 10 Mbps upload while hardwired and not on a VPN are sufficient.

Preferred Qualifications:

• Bachelor’s degree in healthcare administration, Business, or a related field.
• Fluent in communicating both verbally and in writing in both English and Spanish.
• 1+ year of experience in a dental and vision and/or optical office.
• Registered Dental Hygienist, Dental Assistant, or Expanded Function Dental Assistant. Ophthalmic Assistant, Certified Ophthalmic Assistant, or Optometric/Paraoptometric Assistant.
• Strong understanding of Medicaid and Medicare regulatory guidelines.

FLSA Status: Salary/Exempt

National Salary Range: $38,130 - $59,640

How To Stay Safe:

Avesis is aware of fraudulent activity by individuals falsely representing themselves as Avesis recruiters. In some instances, these individuals may even contact applicants with a job offer letter, ask applicants to make purchases (i.e., a laptop or gift cards) from a designated vendor, have applicants fill out W-2 forms, or ask that applicants ship or send packages of goods to the company.

Avesis would never make such requests to applicants at any time throughout our job application process. We also would never ask applicants for personal information, such as passport numbers, bank account numbers, or social security numbers, during our process. Our recruitment process takes place by phone and via trusted business communication platform (i.e., Zoom, Webex, Microsoft Teams, etc.). Any emails from Avesis recruiters will come from a verified email address ending in @Avesis.com.

We urge all applicants to exercise caution. If something feels off about your interactions, we encourage you to suspend or cease communications. If you are unsure of the legitimacy of a communication you have received, please reach out to ITsupport@Avesis.com.

To learn more about protecting yourself from fraudulent activity, please refer to this article link (https://consumer.ftc.gov/articles/how-avoid-scam). If you believe you were a victim of fraudulent activity, please contact your local authorities or file a complaint (Link: https://reportfraud.ftc.gov/#/) with the Federal Trade Commission. Avesis is not responsible for any claims, losses, damages, or expenses resulting from unaffiliated individuals of the company or their fraudulent activity.

We Offer

• Meaningful and challenging work opportunities to accelerate innovation in a secure and compliant way.
• Competitive compensation package.
• 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. We volunteer within our local communities, create educational alliances with colleges, drive a variety of initiatives in sustainability.

Equal Employment Opportunity

At Avēsis, We See You.  We celebrate differences and are building a culture of inclusivity and diversity. We are proud to be an Equal Employment Opportunity employer that considers all qualified applicants and does not discriminate against any person based on ancestry, age, citizenship, color, creed, disability, familial status, gender, gender expression, gender identity, marital status, military or veteran status, national origin, race, religion, sexual orientation, or any other characteristic.  At Avēsis, we believe that, to operate at the peak of excellence, our workforce needs to represent a rich mixture of diverse people, all focused on providing a world-class experience for our clients.  We focus on recruiting, training and retaining those individuals that share similar goals.  Come Dare to be Different at Avēsis, where We See You!