Grievances & Appeals Coordinator

SUMMARY  The Grievance Coordinator is responsible for timely intake, processing, researching, documenting, and responding to grievances referred to Alivi by health plan partners. Responsible for entering pertinent information into the designated portal/database, communicating with contracted providers to resolve cases, communicating with contracted health plan partners, tracking case load aging, escalating issues prior to expiration of standard processing timelines, and maintaining compliance with all processing timeframes established within the department. 
  DUTIES & RESPONSIBILITIES 

• Responsible for the handling of assigned grievances referred by contracted health plan partners, writing acknowledgements, obtaining pertinent records as needed, researching cases, resolving issues and ensuring time frames are met for acknowledgement and resolution. Must comply with all regulatory requirements and policies of Alivi. 

• Responsible for investigating and resolving all issues and/or concerns reported by the health plan through the grievance portal in a timely and efficient manner.  

• Ensure appeal and grievance cases are complete and contain all relevant documentation, including research materials, communications, and any other pertinent information related to the case. 

• Works closely with internal departments to resolve and research health plan member grievances and to obtain additional information to provide to the health plan to adequately resolve and respond to the grievance. 

• Contacts providers and health plan partners to obtain additional information to adequately resolve and respond to assigned grievances. 

• Provides timely resolution of customer complaints, concerns, and inquiries. 

• Responds professionally to all customer requests related to grievances. 

• Demonstrates an understanding of the functions of other departments and affiliates while communicating appropriately to maintain positive working relationships. Supports department in administrative, data management and clerical duties. 

• Responsible for addressing and forwarding fraud and abuse allegations to the Compliance Department for resolution and/or assisting in the investigation in conjunction with the grievance. 

• Participates in staff meetings. 

• Other job duties as assigned by management. 

REQUIREMENTS & QUALIFICATIONS   

• High School Diploma or equivalent. 

• 1-2 years experience in appeals and grievance, utilization management, or member services preferred. 

• Ability to successfully interact with providers, health plan personnel and health plan members. 

• Excellent time management skills. 

• Excellent organizational skills and ability to handle multiple tasks. 

• Excellent verbal and written communication skills. 

• Excellent proficiency in Excel, Word and Access. 

• Attention to detail and accuracy and capability of meeting deadlines consistently. 

• Ability to understand and follow written and verbal instructions. 

• Professional appearance and demeanor. 

• Bilingual skills a plus. 

• Versatility, flexibility, and a willingness to work enthusiastically within a fast paced and constantly changing environment.