Grievance and Appeals Coordinator

Full Time Grievance and Appeals Coordinator
South Country Health Alliance

South Country Health Alliance is seeking a Grievance and Appeals Coordinator to join our team! This role is responsible for the management of his/her assigned caseload involving member complaints received at South Country Health Alliance (South Country) which may include member grievances or appeals. This person will perform advanced and complicated case review duties requiring clinical judgment independent analysis and detailed knowledge of departmental and regulatory procedures.

What Youll Bring:

• An active Minnesota RN License and broad based clinical background;
• 3-5 years Health plan experience and/or experience conducting complaint investigations;
• Proficiency in Microsoft Office especially Word and Excel;
• Knowledge of federal and state regulatory requirements for appeals and grievances;
• Knowledge of MN Medicare and Medicaid
• A B.A. or B.S in Nursing is preferred

Why South Country

South Country Health Alliance is more than a health planwere a mission-driven organization dedicated to improving health and well-being in rural Minnesota communities. Our work is guided by values of communication collaboration stewardship and excellence ensuring that every employee contributes to making a real difference in peoples lives.

Join us and be part of an organization that values community impact employee well-being and innovation.

South Country offers a wide variety of benefits including medical dental vision health savings account contributions PERA Pension paid holidays paid vacation paid sick time and more.

This position is a hybrid position- requiring in office time in Medford MN as organizationally necessary. Remote status will be dependent on experience education skill level and needs of the organization.

Salary for this position starts at $37.14- $45.43/hour based on qualifications and experience.

Must be legally authorized to work in the U.S. (No sponsorship available)

Grievance and Appeals Coordinator

Department: Grievance and Appeals

Reports To: Grievance and Appeals Manager

Pay Grade: 9

Supervises: None

Revision Date: January 2026

JOB SUMMARY:
The Grievance and Appeals Coordinator is responsible for the management of his/her assigned caseload involving member complaints received at South Country Health Alliance (SCHA) which may include member grievances or appeals. This person will perform advanced and complicated case review duties requiring clinical judgment independent analysis and detailed knowledge of departmental and regulatory procedures.

QUALIFICATIONS:
Required: RN with an active license in the State of MN and a broad-based clinical background; 3-5 years health care experience; Knowledge of federal and state regulatory requirements for appeals and grievances; Proficient in Microsoft Office especially Word and Excel.

Preferred: B.A or B.S in Nursing; Health plan experience and/or experience conducting investigations or processing appeals.
Skill Sets: Ability to work independently; Critical thinking skills; Investigative and creative problem-solving skills; Excellent written and verbal communication skills; Ability to work cross departmentally and effectively with business partners including Third Party Administrators (TPAs) health care providers and professionals; Organizational and time management skills.

ESSENTIAL DUTIES and RESPONSIBILITIES:
The duties and responsibilities listed below reflect the general details necessary to describe the essential functions of the position and shall not be construed as the only duties that may be assigned for the position.
% of Total Time
1. Processes member complaints and related requests thoroughly and completely by acquiring appropriate records and/or other information and applying problem-solving skills and investigative methodology as well as clinical knowledge. Cases will be processed in accordance with regulatory requirements and departmental policies and procedures ensuring timely and appropriate determinations. 15%
2. Coordinates the assigned case in its entirety which may require obtaining the assistance of other South Country staff for review/investigation of information; will collaborate effectively with others including but not limited to South Countrys Medical Director Health Services Member Services and Operations departments county staff delegated entities and providers. Works closely with South Countrys Medical Director and other contracted clinicians especially during review of quality-of-care complaints and appeals to ensure necessary and timely completion of case related medical reviews. 15%
3. Maintains accurate and complete case documentation which may include both electronic and hard copy case files. Ensures related correspondence is scanned into the electronic record. 15%
4. At times may need to correspond with external regulatory agencies such as the Minnesota Department of Human Services (DHS) Centers for Medicare and Medicaid Services (CMS) and the Minnesota Department of Health (MDH). This would include work-related functions pertaining to State Appeals (also known as State Fair Hearings) and handling/processing of cases involving external independent review entities. 5%
5. Conducts necessary and appropriate case preparation interviews and record review. Upon initial receipt of complaint/request reviews documentation and/or phone call(s) to ensure accurate identification and classification of concern(s) to properly route/process these cases. Job duties will also include appropriate triaging of cases to determine the need to expedite the cases and/or process in a timely manner according to the members health condition. 15%
6. Completes assigned duties related to internal and external data reporting; this may include tracking and analysis of complaints data on a daily monthly or quarterly basis and may involve preparation and timely submission of reports for South Countrys Quality Assurance Committee Compliance Committee and mandatory annual CMS/quarterly DHS grievance and appeals data reports. 10%
7. As assigned will conduct a review of member phone calls involving complaints and/or related requests for quality purposes; in follow-up to this may need to provide feedback and/or additional guidance as needed to South Country staff who handled the member phone call and related request. 15%
8. As designated by South Countrys G/A Manager completes daily monitoring and processing of any complaints received via CMSs Health Plan Management System (HPMS) Complaints Tracking Module (CTM). In addition to this tracks and monitors quarterly complaint data received from external providers/clinics. 5%
9. Other job duties as assigned within the scope responsibility and requirements of the job. 5%

QUALIFICATION REQUIREMENT
To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge skill and/or ability required.

LANGUAGE SKILLS
Must be able to read and write in English; must communicate in an accurate clear and concise manner.

MATHMATICAL SKILLS
Basic Mathematical skills required.

ACCURACY
The impact of errors or negligence may involve a significant financial loss if an incorrect benefit or clinical appeal decision is made. Errors could also significantly affect enrollees ability to access services.

REASONING ABILITY
Must understand cause and effect relationships and be able to draw conclusions from data regulatory requirements and past practice; requires the use of considerable and broad decision making and complex problem solving (technically abstractly and administratively).

PHYSICAL DEMANDS
The physical demands described represent those that must be met by an employee to successfully perform the essential functions of this job. Where possible reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job the employee is regularly required to talk or listen. The employee frequently is required to sit. The employee is occasionally required to stand walk; use hands to navigate office equipment (i.e. computer telephone etc.) office supplies and reach with hands and arms.
The employee must rarely lift and/or move up to 5 pounds. Specific vision abilities required by this job include close vision distance vision peripheral vision depth perception and the ability to adjust focus

CONTACTS/RELATIONSHIPS
This position works most closely with Member Services Health Services and Operations departments and externally with providers such as physician clinics and hospitals; maintains satisfactory relationships and may include collaboration in executing established policies discussion of ways to reach agreed-upon objectives and securing compliance with approved procedures.

FINANCIAL IMPACT
This position is responsible for ensuring that South Country is following contractual language as promulgated by governmental agencies. Failure to comply with this contractual language could result in breach of contract resulting in a significant financial penalty potential contract cancellation sanctions and/or corrective action.