Grievance and Appeals Coordinator

Rancho Cucamonga, California

Monday through Friday 8a-5p (Mondays & Fridays work from home)

Pay: 23/hour

Requirements: (most important and brief, Spanish Speaking, RN License, etc.)

Job Type: 6 month contract

Summary:

Under the general direction of the Grievance & Appeals Nurse Manager and Grievance Supervisor, the Grievance and Appeals Coordinator is responsible for completing administrative functions and supporting departmental activities for processing Grievance and Appeal cases. The Grievance and Appeals Coordinator is responsible for ensuring that personnel adhere to the guidelines established and outlined in the Grievance and Appeals Resolution System. The Grievance and Appeals Coordinator exercises independent judgment to ensure appropriate escalation protocols when trends or deficiencies are identified.

Responsibilities:

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 Organization.
3. Ensure compliance with the Grievance and Appeals Resolution Process, in accordance with all regulatory agencies.

4. Responsible for providing administrative support to ensure grievance and appeal cases are processed per regulatory guideline and internal department protocol.

5. Maintain and prepare grievance and appeals summary reports, as needed.

6. Speak to health plan members as needed to clarify or obtain any information necessary in order to process a Grievance or an Appeal appropriately.
7. Speak to health plan members as needed to answer any questions regarding their case.

Requirements/Qualifications:

Applicable to Bilingual job code only - Bilingual (English/Spanish) - written and verbal skills required.

• 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.


• High school diploma or GED required.

Key Qualifications

• 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.  


• 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.


• Understanding of and sensitivity to multi-cultural community.