Coordinator, Appeals and Grievances
: Job Details :

Your Future Evolves HereEvolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.Join Evolent for the mission. Stay for the culture.What You'll Be Doing:We are seeking a Grievance and Appeals Coordinator to be a key member of the team. The Grievance and Appeals Coordinator is responsible for receiving, investigating, and resolving member administrative appeals, grievances and provider administrative appeals and supporting the clinical team with clinical appeals. All tasks will be in compliance with regulatory and accrediting agency standards.Collaboration Opportunities:As a Coordinator, Appeals & Grievances, you will be working with an advanced team of coordinators that process Appeals & Grievances for several clients.Together the team maintains service level agreements for each client.What You Will Be Doing:Receive faxes, emails and mail to initiate an appeal or grievance request utilizing multiple software applicationsMake outbound calls when necessary to obtain additional information pertaining to the research of an appeal or grievanceTriage & Assign cases amongst the team on a rotating basisCollect, organize and track information received from a variety of resources to facilitate and expedite the processing of appeals and grievancesGenerate acknowledgement letters for member appeals and grievances in accordance with regulatory standardsInitiate, research and resolve member grievances in accordance with company and regulatory standardsInitiate, research and refer member appeals to the Appeals RNInitiate, research and resolve provider appeals or refer to the Appeals RN, as necessaryGenerate resolution letters, as appropriateUtilize multiple internal and external computer applications and programsMeet established productivity and quality standardsRotating Holiday coverage to intake emergent/urgent casesAct as a back up coordinatorPerform other duties as assignedQualifications Required and Preferred:3 years of experience minimum in processing appeals and grievances -Required3 years of experience within a health plan, managed care organization or third-party administrator -RequiredUnderstanding of appeals process and utilization management -RequiredWorking knowledge of regulatory and accreditation requirements- PreferredExcellent verbal and written communication skills -RequiredExperience in Medicaid with knowledge of NCQA guidance/regulations for appeal and grievance processing -PreferredTechnical Requirements:We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status.If you need reasonable accommodation to access the information provided on this website, please contact...@evolent.comfor further assistance.The expected base salary/wage range for this position is $20-$23/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!For more insights about Evolent Health, click on Life At Evolent ( to learn more!