PRINCIPAL RESPONSIBILITIES:

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 identify 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;
• Frequently communicate with members from intake to completion of a case;
• Provide excellent customer service in order to gather information and communicate disposition;
• 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.

Number of Employees Supervised: 0

EDUCATION OR TRAINING EQUIVALENT TO:

• Bachelor’s degree or equivalent experience preferred
• High School Diploma.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Minimum two years of experience in health services, managed care, hospital, or similar setting.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):

• Knowledge of managed care and medical terminology;
• Experience in a customer service or coordination in a healthcare setting or equivalent experience;
• 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.

Salary Range $26.07-$39.10 Hourly