Grievance and Appeals Coordinator

Position Description

Join our clients dynamic team as a vital link in thier Grievance and Appeals department, where you will play a crucial role in ensuring our members and providers receive the highest standard of care and service. Under the guidance of our Grievance & Appeals Nurse Manager and Grievance Supervisor, you will be at the forefront of processing Grievance and Appeal cases, ensuring compliance, and exercising independent judgment to maintain the integrity of our resolution system. Your expertise will help us identify trends, address deficiencies, and uphold the guidelines that support our mission.

• Maintain a comprehensive understanding of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC.
• Champion the legal rights of Members and Providers to access the Grievance and Appeals Resolution Process within our organization.
• Ensure our processes align with all Health Plan regulatory agencies.
• Provide essential administrative support to streamline the processing of grievance and appeal cases, including:
  • Coordinating, documenting, and tracking all Member and Provider grievances and appeals.
  • Generating clear and precise written correspondence to Providers, Members, and regulatory entities.
  • Ensuring timely dispatch of grievance and appeal letters in compliance with regulatory guidelines.
  • Assisting in filing, tracking, and closing grievances efficiently.
• When handling case intakes, ensure:
  • Proper assignment of new cases based on medical urgency to the appropriate team member.
  • Immediate alert and guidance to team members on investigative approaches and documentation.
• Act as a liaison to facilitate information flow and closure of grievances and appeals within set timelines.
• Keep supervisors informed of ongoing and pending issues with expected resolution plans.
• Prepare and maintain summary reports on grievances and appeals as needed.
• Assist management in evaluating information for potential policy and procedural changes.
• Collaborate with team members to support departmental protocols and organizational vision.
• Incorporate LEAN principles into daily tasks to enhance efficiency.
• Engage with health plan members to clarify or gather information necessary for processing cases.
• Address member inquiries regarding their cases with clarity and empathy.

Requirements

• Three or more years of administrative experience in an office environment, with proficiency in Microsoft Office Suite.
• Experience in a managed care Member Service/Customer Service environment, with prior Medi-Cal and Medicare experience preferred.
• High school diploma or GED required; Bachelor's degree from an accredited institution preferred.
• Valid California Driver's License required.

Key Qualifications

• Excellent communication and interpersonal skills.
• Strong organizational skills, ability to type 45 words per minute, and proficiency in Microsoft Word and Excel.
• Telephone courtesy and multitasking capabilities.
• Attention to detail and ability to prioritize tasks to meet deadlines.
• Ability to learn and adhere to standards and procedures.
• Positive attitude and ability to work effectively in a team setting.
• Sensitivity and understanding of multi-cultural communities.

Additional Information

• Hybrid work environment.

INDH