Grievances & Appeals Coord, D&V


Location: Remote - US only

Job Type: Full time


Salary Range: $31,200 – $68,000

Remote/Hybrid/On-Site: Remote

We’ve Got You Under Our Wing

We are the duck. We develop and empower our people, cultivate relationships, give back to our community, and celebrate every success along the way. We do it all…The Aflac Way.

Aflac, a Fortune 500 company, is an industry leader in voluntary insurance products that pay cash directly to policyholders and one of America's best-known brands. Aflac has been recognized as Fortune’s 50 Best Workplaces for Diversity and as one of World’s Most Ethical Companies by

Our business is about being there for people in need. So, ask yourself, are you the duck? If so, there’s a home, and a flourishing career for you at Aflac.

What does it take to be successful at Aflac?

  • Acting with Integrity
  • Communicating Effectively
  • Pursuing Self-Development
  • Serving Customers
  • Supporting Change
  • Supporting Organizational Goals
  • Working with Diverse Populations

What will you be doing in this role?

  • Comfortable with coordinating among health plan, member and provider where necessary to arrive at a solution acceptable to all parties.

  • Strengths include organization and planning, managing multiple demands, and achieving results.

  • Analytical reasoning interprets and evaluates complex information, while identifying patterns and essential issues.

  • Word processing, spreadsheets, and database software.

  • Superb written and oral communication skills with particular emphasis on presentation skills.

  • Proven ability to build consensus and work effectively within a cross-departmental team.

Education & Experience Required

  • High School Diploma or Equivalent
  • Four years of experience in customer service in healthcare setting handling complex inquiries and requests for service

Or an equivalent combination of education and experience

Principal Duties & Responsibilities

  • Act as a mediator between members and providers in order to provide satisfactory resolutions to complaints about services or treatment received. Each case may require thorough research and will include a documentation process to comply with state and federal applicable reporting requirements.

  • The Grievances & Appeals Coordinator is responsible for notifying the member of outcome within a turnaround time defined by state regulations or the plan requirements (whichever is applicable).

  • Independently reviews the members' case file to determine if representative/appellant is authorized party and if complaint is valid.

  • Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.

  • Partners with all service delivery functions ( i.e. clinical, claims, billing and enrollment) to answer member questions/or works with others to resolve escalated issues

  • Develops and delivers timely and professional communication dealing with complex issues at each step of the process to advise members of the progress and status of their issue.

  • Meets established productivity and quality standards in addition to attendance requirements.

  • Demonstrates problem solving, leadership, and conflict management skills in order to ensure a productive work environment and achievement of goals.

  • Ensure compliance with local, state and federal laws, Medicare regulations and Aflac Dental and Vision policies and procedures.

  • Displays a willingness to support the policies and procedures, and uses appropriate channels for change of such policies.

  • Interact professionally with other employees, providers, members.

  • Work independently while understanding the need to communicate and coordinate work efforts with other staff and organizations.

  • Perform job responsibilities in compliance with all Aflac Dental & Vision Operating Policies and procedures.

  • Complete required annual education courses within the expected timeframes.

  • Be cognizant of and adhere to principles of Patient and Provider Rights and Responsibilities as outlined in Aflac Dental & Vision materials and policy documents

Total Rewards

This compensation range is specific to the job level and takes into account the wide range of factors that are considered in making compensation decisions including, but not limited to: education, experience, licensure, certifications, geographic location, and internal equity. The range has been created in good faith based on information known to Aflac at the time of the posting. Compensation decisions are dependent on the circumstances of each case. This salary range does not include any potential incentive pay or benefits, however, such information will be provided separately when appropriate. The salary range for this position is $31,200 to $68,000.

In addition to the base salary, we offer an array of benefits to meet your needs including medical, dental, and vision coverage, prescription drug coverage, health care flexible spending, dependent care flexible spending, Aflac supplemental policies (Accident, Cancer, Critical Illness and Hospital Indemnity offered at no costs to employee), 401(k) plans, annual bonuses, and an opportunity to purchase company stock. On an annual basis, you’ll also be offered 11 paid holidays, up to 20 days PTO to be used for any reason, and, if eligible, state mandated sick leave (Washington employees accrue 1 hour sick leave for every 40 hours worked) and other leaves of absence, if eligible, when needed to support your physical, financial, and emotional well-being. Aflac complies with all applicable leave laws, including, but not limited to sick and safe leave, and adoption and parental leave, in all states and localities.

You’ve got this!