Appeals/Grievance Coordinator - Health First Health Plan, Full-Time To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship by resolving member complaints in a timely, professional and compliant manner. Success in this position will be based on the individual's ability to effectively research, document, analyze and resolve complaints according to complex and strict rules, while identifying and communicating issues appropriately. Primary Accountabilities * Maintaining an understanding of laws, regulations, standards and procedures that guide complaint handling, and resolving complaints in compliance with applicable rules related to procedures and timeframes with them. * Correctly identifying and interpreting medical, contractual or legal issues related to complaints and communicating them to the appropriate decision-makers. * Preparing thorough and well-documented case files for internal reviewers, including physician review for medical necessity * Composing professional, legally-sound and customer-friendly correspondence related to member complaints * Collaborating effectively with other Health First Health Plans departments to resolve member complaints * Maintaining confidentiality at all times, following departmental and organizational confidentiality guidelines * Presenting a professional image to the public * Elevating issues to senior management as necessary to minimize financial risks. * Reporting trends to help reduce medical or pharmacy costs * High School education or equivalent; some college preferred. * Minimum one (1) year of experience with healthcare business office or health plan. * Advanced knowledge of prescription drug coverage concepts. * Advanced knowledge of health care financing and health care delivery. * Advanced knowledge of Medicare eligibility, coverage and payment provisions. * Advanced knowledge of commercial insurance provisions. * Experience working collaboratively with others to achieve goals. * Consistent demonstration of professional behavior and commitment to quality * Demonstrated ability to communicate professionally **Primary Location: **United States-Florida - Brevard County-Rockledge **Work Locations: ** **Job: **Health First Health Plans (Health Insurance) **Organization: **Health First **Job Level: **Associate **Schedule: **Full-time