Job Details

Hybrid: Applicants must be a California resident as of their first day of employment.

PRINCIPAL RESPONSIBILITIES:

Under general direction of the Grievance and Appeals Supervisor, the Grievance and Appeals (G&A) Coordinator III willreview, analyze and process complex / quality of care / high level grievances and appeals for all lines of business and the completion of written communication documents to convey determination. The coordinator is responsible for processing and monitoring the grievance and appeals process and corresponding documentation continuously for quality and accuracy while working independently within a team environment.

Principle responsibilities include:

• Address and respond to telephonic and written inquiries regarding member complex / quality of care / high level grievances, adverse benefit determination appeals an expedited concerns ensuring correct identification and categorization of one or more issues raised by the member, members representative or provider on behalf of member.
• Independently investigate, research, review, and resolve complex / quality of care / high level member grievances, appeals and expedited concerns within regulated timeframes, while clarifying issues and educating members in the process.
• Handle escalated member and provider concerns with the dual goal of ensuring satisfaction and retention.
• Represents the highest level of expertise that is required to respond to complex / quality of care / high level grievances, adverse benefit determination appeals an expedited concern.
• Perform research and identify key policy provisions such as clinical guidelines, plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations.
• Interpret member contracts, internal policies, and procedures as well as regulatory and accreditation requirements.
• Summarize cases including articulation of member's perception and present essential information and prepare clinical cases to RNs and Medical Directors for review.
• Frequently communicate with members from intake to completion of a case.
• Provide excellent customer service in order to gather information and communicate disposition.
• Generate written correspondence to members, providers and regulatory agencies.
• Interprets and explains health plan benefits, policies, procedures, and functions to members and providers both verbally and in writing, ensuring that all communication meets regulatory standards and contractual obligations.
• Identify system issues that result in failure to provide appropriate care to members or failure to meet service expectations.
• Thoroughly document the investigation and resolution of each case.
• Maintain an accurate and complete appeals/grievance record in the electronic database.
• Coordinate and prepare the Alliance component of the State Fair Hearing, MAXIMUS, Independent Medical Review (IMR), and DMHC appeal processes.
• Ensure compliance with state and federal regulations as they relate to appeal and grievance issues.
• Serve as the liaison with other departments to resolve grievance issues.
• Ensure timely communication with the Supervisor on all issues having potential risk and or impact on operations.
• Serve as a mentor to new hires or team members requiring additional support as assigned.
• Provide support to Team Lead and Supervisor.
• Engage in special projects as assigned/requested.
• Other duties as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

• Ability to manage a caseload of a minimum of 30 complex cases a month.
• Coordinate complex grievance and appeal activities by receiving, handling, and resolving member issues and operational issues with other organizational staff.
• Achieve compliance, quality, and production standards.
• Ensure all cases and correspondence are managed in accordance with accreditation, regulatory, contractual compliance, and timeliness standards.
• Maintain a pertinent documents, case files, and correspondence in an organized, confidential, and secure manner.
• Perform ongoing data entry.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

PHYSICAL REQUIREMENTS

• Constant and close visual work at desk or computer;
• Constant sitting and working at desk;
• Constant use of keyboard and/or mouse;
• Constant use of telephone headset;
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person;
• Frequent lifting of folders and various objects weighing between 0 and 30 lbs;
• Frequent walking and standing;

Number of Employees Supervised: 0

MINIMUM QUALIFICATIONS:

EDUCATION OR TRAINING EQUIVALENT TO:

• HS diploma or equivalent, required.
• Associates and/or bachelor's degree, preferred.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Minimum of two to three years of Grievance and Appeals Coordinator experience, required.

SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE)

• Knowledge of managed care and medical terminology;
• Experience in a customer service or coordination in a healthcare setting or equivalent experience;
• Excellent verbal and written communication skills;
• Team player who builds effective working relationships;
• Strong organizational skills;
• Proficient experience in Microsoft Word, Excel, Access, Outlook, and PowerPoint; and
• Excellent verbal and written communication skills a must.

SALARY RANGE: $34.80 - $52.21 Hourly

The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.