Coordinator, Appeals and Grievances – Evolent Health – Remote

It’s Time For A Change…

Your Future Evolves Here

Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving power that brings us to work each day. We believe in embracing new ideas, testing ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference in everything from scrubs to jeans.

Are we growing? Absolutely. We have seen about 30% average growth over the last three years. Are we recognized? Definitely. We were named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving important Diversity and Inclusion (D&I) efforts: Evolent achieved a 95% score on its first-ever submission to the Human Rights Campaign’s Corporate Equality Index; was named on the Best Companies for Women to Advance List 2020 by Parity.org; and we publish an annual Diversity and Inclusion Annual Report to share our progress on how we’re building an equitable workplace. We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.

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.

Responsibilities:

• Receive inbound calls, faxes, emails and mail to initiate an appeal or grievance request utilizing multiple software applications
• Make outbound calls when necessary to obtain additional information pertaining to the research of an appeal or grievance
• Collect, organize and track information received from a variety of resources to facilitate and expedite the processing of appeals and grievances
• Generate acknowledgement letters for member appeals and grievances in accordance with regulatory standards
• Initiate, research and resolve member grievances in accordance with company and regulatory standards
• Initiate, research and refer member appeals to the Appeals RN
• Initiate, research and resolve provider appeals or refer to the Appeals RN, as necessary
• Generate resolution letters, as appropriate
• Utilize multiple internal and external computer applications and programs
• Meet established productivity and quality standards
• Perform other duties as assigned

Qualifications:

Required

• 2 years of experience minimum in processing appeals and grievances
• 3 years of experience within a health plan, managed care organization or third-party administrator
• Understanding of appeals process and utilization management
• Working knowledge of regulatory and accreditation requirements
• Excellent verbal and written communication skills

Preferred

• Experience in Medicare Advantage plan with knowledge of CMS guidance/regulations for appeal and grievance processing
• Bachelor’s Degree
• Certified coder

Technical requirements:

Currently, Evolent employees work remotely across all 50 states temporarily due to COVID-19. As such, 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 Health is committed to the safety and wellbeing of all its employees, partners and patients. We currently require all employees who may voluntarily return to our Evolent offices to be vaccinated and invite all employees regardless of vaccination status to remain working from home.

As we continue to evaluate re-opening our offices more fully and begin to have specific roles that will require face to face interaction with our providers and patients in client facilities or homes, all employees must be prepared to meet our vaccine requirements with or without accommodation at that time.”

Evolent Health 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.