Employment Type:

Shift:

Description:

Why MediGold

MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. Were dedicated to providing excellent customer service cost-effective care and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology financial analysis audit provider relations and more.

Position Purpose:

The Appeals and Grievance Coordinator is responsible for the processing and resolution of appeals grievances and disputes from members and providers

What You Will Do:

• Document all appeal requests or grievances upon receipt in the operating systems and routes cases to appropriate clinical personnel for review.
• Obtain confidential medical records from providers offices utilizing secure methods.
• Responsible for preparation of case files and review with clinical colleagues.
• Screen all incoming grievances appeals and provider claim dispute to ensure they are within compliance requirements of CMS guidelines and corporate policies.
• Gather analyze and report verbal and written member and provider complaints grievances and appeals in accordance with Federal regulations and time constraints.
• Conduct grievance and appeal investigations and provider claim dispute investigations through internal and external interviews chart and contract audits inspection and interpretations of appropriate CMS guidance and policies.
• Prepare background case summary and case files with records for submission to the Independent Review Entity (IRE) and ensures that cases are compliant and required timeframes are met.
• Obtain required documents and completely prepare cases for Appeals Committee (MAC) review Administrative Law Judge (ALJ) Hearings.
• Prepares and reviews data universes for the Centers for Medicare and Medicaid Services (CMS) audits.
• Participates in regular monitoring efforts and reports trending and outliers to senior management.
• Responsible for ensuring 5-Star (maximum) ratings from CMS for appeals and grievance related measures. STAR ratings have a direct correlation on payment methodology and reimbursement to the organization.
• Maintain compliance of all regulatory requirements that apply to beneficiary protection areas of appeals and grievance.
• All other duties as assigned.

Minimum Qualifications:

• Education: Bachelors degree or an equivalent combination of education and experience.

• Experience: Three years of customer service experience or appeals and grievance experience preferably in managed care (health insurance) or another health care setting.

• Legal or regulatory background or experience highly desired

• Strong written and verbal communication skills and demonstrated public speaker/educator desired.

• Ability to interpret and apply Federal law and regulatory requirements ensuring compliance with Medicare Managed care obligations.

• Ability to educate staff members providers and enrollees about the appeals and grievance process.

• Familiarity with claims processing coordination of benefits and use of claims processing system.

• Ability to follow Federal guidelines from CMS and Ohio Department of Insurance (ODI) for appeal and grievance resolution processes and requirements.

Position Highlights and Benefits:

• Mount Carmel Health System recognized by Forbes in 2025 as one of Americas Best State Employers.
• Competitive compensation and benefits packages including medical dental and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• RN to BSN tuition 100% paid at Mount Carmels College of Nursing.
• Relocation assistance (geographic and position restrictions apply).
• Employee Referral Rewards program.
• Mount Carmel offers DailyPay - if youre hired as an eligible colleague youll be able to see how much youve made every day and transfer your money any time before deserve to get paid every day!
• Opportunity to join Diversity Equity and Inclusion Colleague Resource Groups.

Ministry/Facility Information:

Mount Carmel a member of Trinity Health has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our five hospitals free-standing emergency centers outpatient facilities surgery centers urgent care centers primary care and specialty care physician offices community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohios largest undergraduate graduate and doctor of nursing programs. If youre seeking a rewarding career where your purpose passion and desire to make a difference come alive we invite you to consider joining our team. Here care is provided by all of us For All of You!

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race color sex age national origin religion sexual orientation gender identity status as a veteran and basis of disability or any other federal state or local protected class.

Our Commitment

Rooted in our Mission and Core Values we honor the dignity of every person and recognize the unique perspectives experiences and talents each colleague brings. By finding common ground and embracing our differences we grow stronger together and deliver more compassionate person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability veteran status or any other status protected by federal state or local law.