Manages all non-clinical aspects of member and provider appeals and grievances to ensure accurate intake, validation, timely case processing, and compliance with federal, state, and internal policy requirements. This role performs case setup, triage, documentation tracking, letter drafting, correspondence management, and coordination with clinical and operational teams. The coordinator supports member advocacy by ensuring each case proceeds through the proper workflow with a high degree of accuracy, professionalism, and regulatory adherence.
At MJHS, we are more than a workplace; we are a supportive community committed to excellence, respect, and providing high-quality, personalized health care services. We foster collaboration, celebrate achievements, and promote fairness for all. Our contributions are recognized with comprehensive compensation and benefits, career development, and the opportunity for a healthy work-life balance, advancement within our organization and the fulfillment of having a lasting impact on the communities we serve.
Benefits include:
MJHS companies are qualified employers under the Federal Government’s Paid Student Loan Forgiveness Program (PSLF)
Review newly created cases to confirm accurate classification or reassignment to correct classification as necessary.
Review history and identify additional information that may be required as part of the investigation.
Respond in a timely manner to written and/or verbal appeals and grievances submitted by members and providers in accordance with Elderplan Contract Benefits, CMS, and DOH regulations.
Documents all relevant information in the Appeals and Grievances determination process within the appropriate designated areas of the A/G system.
Maintain regulatory compliance and company policy through thoughtful management of assigned caseload.
Presents cases to the Appeals & Grievances File Review Team as needed.
Successfully complies with the accuracy of case files in key performance indicators during monitoring and auditing activities (95% of audited case files)
Job details are sourced from the employer's original posting.
Open job postingAbout the company
MJHS is a healthcare organization providing a range of services including home care, hospice, and managed long-term care.