Appeals and Grievances Coordinator

 

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

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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.

Avēsis is a rapidly growing eye care, dental and hearing company serving approximately 8.5 million members for both commercial and government programs. As an Appeals and Grievances Specialist your duties include researching, resolving, and responding to appeals and grievances initiated by members and providers within contractually required time frames. Performance of these functions includes working with key Avesis team members, including Account Managers, Professional Consultants, and staff from Provider Services, Claims, and Customer Services departments to research and resolve appeals and grievances received through state insurance departments, the Better Business Bureau, Department of Insurance, and representatives from health plan partners who have contracted with Avesis for vision, dental or hearing program services. The Appeals & Grievance Specialist also interacts with other Avesis internal departments to research and resolve appeals and grievances in a timely manner. All assigned work requires close attention to detail to ensure that issues are fully and accurately addressed and are resolved and reported in a manner consistent with contracted requirements.

Essential Job Functions:

• Maintaining timely and effective communication with staff from other Avesis departments as well as those from contracted health plans regarding complaints, appeals and grievances
• Logging, tracking, and ensuring completion of all appeals and grievance cases in compliance with contract service standards
• Reviewing, researching, and documenting complaints, appeals and grievances using Avesis customer service, claims and internal systems applications
• Preparing and transmitting acknowledgement and final response letters in the format required by each contracted health plan
• Transmitting appeals of clinical denials to the appropriate professional for review and tracking review completion to ensure final closure of the associated case
• Maintaining documentation associated with complaints, appeals and grievances to ensure responses are timely and in compliance with all applicable regulations and contracted timeframes
• Achieving a high level of workload volume, ensuring accuracy and compliance with scheduled deadlines
• Other duties as assigned

Requirements:

• High School diploma or equivalent certification
• 1+ year of experience in Appeals and grievances, Claims or Utilization Management
• 1+ year experience in a dental and/or optical office is preferred.
• Proficient use of Microsoft Office suite applications and other windows-based software applications

Preferred Requirements:

• 1+ year of experience in the Medicaid and Medicare lines of business

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!

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