Job Number: 1287

Workplace Type:

Position Title: Appeals and Grievance Support Clerk

External Description:

Appeals & Grievance Administrative Support- Seasonal

Summary

Responsible for providing daily administrative support to the Appeals & Grievance Unit of the Member Experience Department.

 

Essential Duties and Responsibilities

 

Essential duties and responsibilities include, but are not limited to:

 

Member Services

 

1. Tracks all incoming member correspondence in the A&G database for case assignment.
2. Responsible for the daily logging, tracking, and monitoring of incoming Appeals & Grievances (CTMs, Grievances, Appeals, Fast Tracks, etc.,) through multiple channels.
3. Communicates and faxes grievance/appeal response requests to appropriate parties for the gathering of all pertinent and relevant information from the member, member representative or provider regarding the member’s concerns.
4. Conducts follow up calls to providers and/or medical groups for requested documentation and ensures timely receipt and compliance with timelines set forth for compliance with CMS guidelines. All point of contacts are thoroughly documented in member’s case file.
5. Responsible for assembly of and maintaining and protecting all member A&G case files in an organized fashion.

1. 5. Maintains confidentiality and upholds standards for privacy and data integrity and  

     security of the appeals and grievance case information.

1. Maintain a positive and professional relationship with AHC staff, providers,

           members, and regulators.

1. Any other duties as assigned by the Department Manage or Director.

 

 

Supervisory Responsibilities

This job has no supervisory responsibilities.

 

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

1. Education and/or Experience: High school diploma or general education degree (GED); or one to three months related experience and/or training; or equivalent combination of education and experience.
2. Certificates, Licenses, Registrations: None required.
3. Other Qualifications:
4. 1. Basic Computer Skills, 30 WPM (Microsoft Outlook, excel, word)
   2. 10-Key by Touch
   3. Good Communication Skills
   4. Previous front office experience preferred

 

 

Skills and Abilities

 

1. Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence.
2. Mathematical Skills: Ability to add and subtract two digit numbers and to multiply and divide with 10’s and 100’s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
3. Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.
4. 1. Excellent communication skills, oral and written.

 

 

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

1. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
2. The employee is frequently required to walk; stand; reach with hands and arms.
3. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
4. The employee must occasionally lift and/or move up to 10 pounds.
5. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

 

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

1. The noise level in the work environment is usually moderate.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Appeals & Grievance Admin Support (Temporary)

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].