Appeals & Grievances Coordinator

GuideWell Source

. Review appeal and grievance cases from members, member representatives, treating physicians, and non-participating providers according to regulatory guidelines and timeframes .

Posted 10/28/2026full-timeJacksonville • Florida • United StatesMid-LevelSenior💰 $20 - $33 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in managing appeals and grievances within Medicare guidelines, utilizing strong analytical and problem-solving skills to resolve complex cases. Proficient in using various Medicare databases and tools to document and communicate case resolutions effectively.

Highest-signal resume keywords

Medicare Product KnowledgeExperience Using SiebelExperience Using DiamondAnalytical And Problem-Solving SkillsExcellent Interpersonal Skills

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Case ReviewGrievance ResolutionClaims ProcessingDocumentationResearch SkillsAttention To DetailMulti-Priority ManagementIndependent Decision-Making

Soft Skills

Interpersonal SkillsCollaborationOrganizational Skills

Tools & Technologies

JIVAProviderConnectCustomer ConnectERCMS RADMDMagellanBlue 2

Certifications & Qualifications

High School DiplomaGED

Industry Keywords

MedicareUtilization ManagementCMSOIRDFS

About the role

Key responsibilities & impact

Review appeal and grievance cases from members, member representatives, treating physicians, and non-participating providers according to regulatory guidelines and timeframes
Classify cases correctly and review for potential expedited requests
Resolve complex standard or expedited grievances, appeals, and disputes involving dissatisfaction, reimbursement, medical necessity, Utilization Management, and benefits
Prioritize case workload to meet required timeframes, SLAs, and written notification requirements
Access MAAGC, JIVA, Diamond, Siebel, ProviderConnect, Client Letter, ERCMS RADMD, Magellan, and Blue 2 to gather case data and document resolutions
Conduct research and document relevant details, actions taken, outreach, and supporting documents
Coordinate with internal business partners and gather data or medical records for clinical decisions, delegated vendors, claims, and network cases
Complete research and documentation to render final determinations with verbal or written notification to appellants
Contact members, providers, and internal and external business partners to resolve appeals and grievances
Facilitate escalated provider and member calls and issues, escalating to the Manager as needed

Requirements

What you’ll need

3+ years related work experience, including experience in Member Contact, Enrollment, Maintenance and Billing (EM&B), Claims or Medicare
High school diploma or GED
Experience using Siebel, Diamond, JIVA and other Medicare databases
Ability to work a flexible schedule with overtime and weekends when needed
Medicare product knowledge
Ability to work independently and collaboratively as a team member
Excellent interpersonal skills and ability to recognize, understand, and respond to sensitive member issues or concerns
Ability to manage multiple priorities
Analytical and problem-solving skills with attention to detail
Preferred: Bachelor’s degree
Preferred: Strong working knowledge of Medicare Advantage, Supplement, Frozen Products, CMS, OIR, DFS and other regulatory requirements
Preferred: Proven organizational skills with strong attention to detail
Preferred: Proven ability to work independently, collaboratively, and use appropriate judgment to make independent decisions by following guidelines
Preferred: Intermediate PC skills, including MS Word, Excel, and PowerPoint
Preferred: Hands-on experience processing Medicare Claims, Written Inquiries or EM&B transactions
Preferred: Current experience with JIVA, Diamond, Siebel, Provider Connect, Customer Connect Client Letter, ERCMS RADMD, Magellan, and Blue 2

Benefits

Comp & perks

Medical, dental, vision, life and global travel health insurance
Life insurance
Short- and long-term disability programs
Leave programs to support personal circumstances
Retirement Savings Plan including employer match
Paid time off
Volunteer time off
10 holidays
2 well-being days
Additional voluntary benefits
Comprehensive wellness program
Opportunities for incentive or commission compensation
Annual reviews with pay for performance considerations for base pay increases
Hybrid work arrangement