Coordinator - Grievance and Appeals
Major Functions
1. Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC.
2. Understand Member and Provider legal rights to access the Grievance and Appeals Resolution Process, within the respective Provider Organizations.
3. Ensure compliance with the Grievance and Appeals Resolution Process, in accordance with all Health Plan regulatory agencies.
4. Responsible for providing administrative support to ensure grievance and appeal cases are processed per regulatory guideline and internal department protocol including:
a. Coordinate, document and track all Member and Provider grievances and appeals.
b. Generates written correspondence to Providers, Members, and regulatory entities using appropriate grammar and punctuation.
c. Ensure all appropriate grievance and appeal letters are sent out within regulatory compliance guidelines.
d. Assist personnel in filing, tracking and closing Member and Provider grievances.
5. When designated to intake cases, the Grievance and Appeals Coordinator will ensure the following:
a. Assign new cases as received for medical urgency and assign to appropriate Grievance Team Member for investigation and resolution.
b. Alert assigned Team Member to any immediate needs, provide guidance regarding depth of investigation, best investigative approach, and manner of documentation, such as close oral case as a “1-day” (no written notification required), obtain verbal or written response from provider as indicated, or resolve internally with no provider input required.
6. Act as a liaison between departments to coordinate information and close grievances and appeals within regulatory timelines.
7. Keep the Grievance and Appeals Supervisor aware of “open” & “pending” grievance/appeal issues and expected resolution measures.
8. Maintain and prepare grievance and appeals summary reports, as needed.
9. Assist IEHP management in the assessment of grievance and appeal information for the potential change to policies and procedures.
10. Responsible for working with Team Members to support the protocols and goals of the department and the vision of the organization.
11. Demonstrate a commitment to incorporate LEAN principles into daily work.
12. Speak to health plan members as needed to clarify or obtain any information necessary in order to process a Grievance or an Appeal appropriately.
13. Speak to health plan members as needed to answer any questions regarding their case.
Experience Qualifications
Three or more (3+) years of administrative experience in an office environment, including use of Microsoft Office Suite. Demonstrated superior interpersonal and administrative skills commensurate with years of experience.
Preferred Experience
Experience in a managed care Member Service/Customer Service environment. Prior Medi-Cal and Medicare experience helpful. Previous experience documenting and resolving Member and Provider grievances and appeals.
Education Qualifications
High school diploma or GED required
Preferred Education
Bachelor's degree from an accredited institution preferred
Drivers License Required
Knowledge Requirement
Understanding of and sensitivity to multi-cultural community
Skills Requirement
Excellent communication and interpersonal skills. Strong organizational skills, typing 45 words per minute, proficient in Microsoft Word and Excel, and data entry experience are essential.
Abilities Requirement
Telephone courtesy. Ability to handle multiple tasks. Strong attention to detail and ability to prioritize work to ensure adherence to task deadlines. Ability to learn and follow standards and procedures. Positive Attitude and ability to work in a team setting.
