• Grievance & Appeals Clerk

    Location US-CA-Alameda
    Posted Date 3 weeks ago(5/1/2018 7:21 PM)
    Job ID
    2018-1787
    # of Openings Remaining
    1
    Experience (Years)
    2
  • Overview

    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.

    Responsibilities

    · 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.

     

     

    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.

    Qualifications

    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.

     

    Pay Range:

    $18.57 - $27.86

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