Grievance and Appeals Coordinator

US-CA-Alameda
4 weeks ago
Job ID
2017-1717
# of Openings Remaining
1
Experience (Years)
3

Overview

Under general direction of the Manager, Grievance and Appeals, the Grievance and Appeals (G&A) Coordinator will review, analyze and process grievances and appeals for all lines of business.

Responsibilities

Principal responsibilities include:

 

Grievances and Appeals:
· Conduct investigation and review of member grievances and appeals involving provision of service and benefit coverage issues;

· Perform research and identfy key policy provisions such as clinical guidelines, plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations;

· Summarize cases including articulation of member’s perception and present essential information to Medical Director for review;

· Contact customers to gather information and communicate disposition of the case and documents interactions; 

· Generate written correspondence to members, providers and regulatory agencies;

· Identify system issues that result in failure to provide appropriate care to members or failure to meet service expectations;

· Ensure appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory agencies or member needs;

· Thoroughly document the investigation and resolution of each case;

· Coordinate the Alliance component of the State Fair Hearing, MAXIMUS, Independent Medical Review (IMR), and DMHC appeal processes.

· Ensure compliance with state and federal regulations as they relate to appeal and grievance issues;

· Serve as the liaison with other departments to resolve grievance issues;

· Maintain an accurate and complete appeals/grievance record in the electronic database.

 

General:
· Maintain compliance with DMHC regulatory requirements and DHCS contractual obligations;

· Ensure timely communication with the Manager on all issues having potential risk and or impact on operations;

· Handle escalated member and provider concerns with the dual goal of ensuring satisfaction and retention;

· Make decisions within department guidelines and policies;

· Maintain a pertinent documents, case files, and correspondence in an organized, confidential, and secure manner;

· Maintain databases for tracking and reporting purposes; and

· Complete other duties and special projects as assigned.

 

ESSENTIAL FUNCTIONS OF THE JOB

· Coordinate grievance and appeal activities by receiving, handling, and resolving member issues and operational issues with other organizational staff;

· Perform ongoing data entry; and

· Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

 

PHYSICAL REQUIREMENTS

· Constant and close visual work at desk or computer;

· Constant sitting and working at desk;

· Constant use of keyboard and/or mouse;

· Constant use of telephone headset;

· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person;

· Frequent lifting of folders and various objects weighing between 0 and 30 lbs;

· Frequent walking and standing; and

· Occasional driving of automobiles.

Qualifications

EDUCATION OR TRAINING EQUIVALENT TO:

 

· Bachelor’s degree in Health Services or related field or equivalent experience.

 

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

 

· Minimum three years of experience in managed care, hospital, or similar setting.

 

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

 

· Fluent in a threshold language desired: Spanish, Cantonese or Vietnamese;

· Knowledge of managed care and medical terminology;

· Experience in quality and utilization management systems;

· Excellent verbal and written communications skills;

· Team player who builds effective working relationships;

· Strong organizational skills;

· Proficient experience in Microsoft Word, Excel, Access, Outlook, and PowerPoint; and

· Excellent verbal and written communication skills a must.

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