Under general supervision of the Grievance and Appeals Manager performs a variety of complex, responsible and confidential duties requiring a thorough knowledge of organizational procedures and precedents; perform routine clerical, administrative duties in support of the Grievance and Appeal Department. This position requires the ability to work independently, maintain confidentiality, exercising judgment and initiative.
· Provide administrative support to the Grievance and Appeals Department and the Grievance and Appeals directors and managers as needed.
· Answer telephone calls and tactfully handle inquiries and/or transfer calls to appropriate party.
· Monitor and respond to incoming calls, emails, faxes and mail as directed by the Grievance and Appeal staff and complete intake of new grievance and appeal cases.
· Independently respond to other departments, letters and general correspondence for inquiries of a routine nature.
· Assist the Grievance and Appeal staff in initiation or completion of cases or projects and work with the Grievance and Appeal Lead to support day to day operations.
· Prepare Grievance and Appeal cases by printing, labeling and organizing files for clinical review. May require frequent use of medical or technical terminology and which combines materials from several sources.
· Prepare meeting agendas, relevant supporting documentation, keep minutes of meetings, and send recap information to the department on a weekly basis.
· Manage work in a confidential manner; ensuring information is shared with internal and external individuals as appropriate.
· Maintain appointment schedules and calendars for the Grievance and Appeal Unit; gather information and contact meeting participants.
· Assist in compiling files/documents for regulatory audits and familiarize self with NCQA, DMHC, DHCS, and NCQA regulations as they apply to position.
· Operate general office equipment such as personal computer, copier, fax, and other office machines.
· Perform 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.
EDUCATION OR TRAINING EQUIVALENT TO:
· High school diploma or equivalent experience.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· 2 years related administrative experience.
· 1-2 years of customer service experience (telephonic preferred).
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· 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.
$18.57 - $27.86