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.
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.
· 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.
· 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.
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.