Appeals & Grievance Coordinator

Job Description:

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. Acts as the primary investigator and contact person for member and provider grievances and appeals.

GENERAL DUTIES/RESPONSIBILITIES :
1.    Acknowledges the receipt of all grievance/appeals, and CTM (Complaint Tracking Module).
2.    Gathers pertinent and relevant information from the member and/or provider regarding the grievance/appeal, determines the appropriate resolution of the grievance/appeal per standard policies and procedures; and notifies the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.
3.    Composes written correspondence to members in accordance to plan policy and CMS Guidelines.
4.    Conducts non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal.
5.    Thoroughly documents all action taken on behalf of the member or provider to resolve the grievance/appeal.
6.    Ensures that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy.
7.    Prepares case files for Medical Director Review and external (including IRE) review of grievances/appeals as appropriate.
8.    Prepares clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors).
9.      Maintains accurate and timely documentation, including complete files of all grievances/appeals. Prepares monthly and quarterly reports as requested.
10.    Identifies training opportunities and potential system and process improvements relating to grievance/appeal data. 
11.    Participates 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.
12.    Other duties as assigned.

Job Requirements:

Experience:

• Required: Two years’ experience in data entry and general office background.
Three years of customer service experience. Minimum 1 year Member Services or similar experience.

• Preferred: 2 years healthcare or insurance experience in a senior setting.

Education:

• Required: High School Diploma or GED.  

• Preferred: Associate degree (A.A.) degree.

Training:

• Required:

• Preferred:

Specialized Skills:

• Required:

• Knowledge of MediCal and Medicare Managed Care Plans.
• Ability to Keyboard/Type 40+ words per minute and use the 10-key by touch.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• 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.
• Problem-Solving Skills:  Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.

• Preferred: Bi-lingual (English/Spanish)

Licensure:

• Required: None

Work Environment:

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.

Essential Physical Functions:

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.

1 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.

2 The employee is frequently required to walk; stand; reach with hands and arms.

3 The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.

4 The employee must occasionally lift and/or move up to 20 pounds.

5 Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Pay Range: $44,790.00 - $67,185.00