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Robert Half Appeals & Grievance Coordinator in Mid-Wilshire, California


A Medical IPA located in the Mid-Wilshire area is in need of Appeals & Grievance Coordinator. The Appeals & Grievance Coordinator will be responsible for the investigation, documentation and resolution of participant appeals in compliance with State/Federal law, rules, and guidelines. The Appeals & Grievance Coordinator will perform research and utilize extensive claims knowledge to respond to inquiries and interpret plan/policy provisions.

Duties Include:

· Work independently using discretion and independent judgment under the general supervision of the department manager and within broad parameters of policy established by management:

· Conduct research to advise management on medical claims issues and develop guidelines for use by the examiners or Participant Services Representatives when necessary.

· Research correspondence and appeals submitted by participants and providers.

· Manage documentation and correspondence for all appeals cases.

· Prepare and write appeals cases and present to the Benefit Committee.

· Coordinate reviews regarding the medical necessity of services with the Health Plan’s medical consultants. Write determination letters regarding the outcome of the reviews and send to the applicable participant/provider.


Medical Claims

Medical Billing

Medical Terminology

Medical Appeals

Medical Grievances

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