Appeals & Grievance Coordinator
Location: Orange, California US
Job Number: 2129
Position Title: Appeals & Grievance Coordinator
Appeals & Grievance Coordinator
The Appeals & Grievance Coordinator is responsible for the day to day functions of the tracking and trending of all grievances, appeals, and complaints received within the Member Services Department. The coordinator will act as the primary investigator and contact person for member and provider grievances and appeals.
Essential Duties and Responsibilities
(May include but are not limited to:)
- Will appropriately acknowledge the receipt of all grievance/appeals, and CTM (Complaint Tracking Module).
- Responsible for the gathering of all pertinent and relevant information from the member and/or provider regarding the grievance/appeal, determining the appropriate resolution of the grievance/appeal per standard policies and procedures; and notifying the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.
- Compose written correspondence to members in accordance to plan policy and CMS Guidelines.
- Conduct non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal.
- Thoroughly document all action taken on behalf of the member or provider to resolve the grievance/appeal.
- Ensure that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy.
- Prepare case files for Medical Director review and external (including IRE) review of grievances/appeals as appropriate.
- Prepare clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors).
- Maintain accurate and timely documentation, including complete files of all grievances/appeals. Prepare monthly and quarterly reports as requested.
- Identify training opportunities and potential system and process improvements relating to grievance/appeal data.
- Participate in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements as well as participate in periodic CMS Audit preparations and regulator meetings/interviews.
- Maintain a positive and professional relationship with plan staff, providers, members, and regulators.
- Other duties as assigned.
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.
- Education and/or Experience: High school diploma or general education degree (GED)
- Certificates, Licenses, Registrations: None required.
- Other Qualifications:
- Knowledge of Medi-Cal or Medicare Managed Care Plans.
- Three to five years customer service experience.
- Two to three years of Appeals & Grievance preferred.
- Bi-lingual (English/Spanish) preferred.
Skills and Abilities
- 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. Ability to speak effectively before groups of customers or employees of the organization.
- 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.
- Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
- Computer Skills: Strong computer skills.
- Other Skills and Abilities:
- Excellent communication skills.
- Excellent written skills
- Good telephone techniques.
- Excellent data entry.
- Strong organizational skills.
- Type 40+ words per minute.
- Experience with 10-key by touch.
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.
- 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.
- The employee is frequently required to walk; stand; reach with hands and arms.
- The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
- The employee must occasionally lift and/or move up to 20 pounds.
- Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.
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.
- The noise level in the work environment is usually moderate.
Location City: Orange
Location State: California
Community / Marketing Title: Appeals & Grievance Coordinator
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