Grievance and Appeals Coordinator I / Job Req 956599809

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

PRINCIPAL RESPONSIBILITIES:

Under general supervision of the Grievance and Appeals Supervisor, the Grievance and Appeals Coordinator I is an entry level position that performs a variety of duties requiring a thorough knowledge of organizational policies and procedures; performs routine administrative and coordinating duties in support of the Grievance and Appeal Department This position requires the ability to work independently, maintain confidentiality, exercising judgment and initiative.

• Provide administrative and coordination support to the Grievance and Appeals Department.
• Monitor and respond to incoming calls, emails, faxes and mail as directed by the Grievance and Appeal staff and complete intake of new grievance and appeal cases.
• Accurately document all contacts and maintain detailed grievance and appeals case files per department standards/guidelines in our processing systems.
• Provide education and status on previously submitted pre-authorizations or pre- determination requests for both medical and pharmaceutical benefits, and previously opened grievances.
• Contact customers to gather information and commincate disposition of cases; documents interactions.
• Speak with members and providers on the phone to gather information about cases.
• Communicate with people calmly and respectfully (even when someone is not calm and respectful).
• Tactfully handles inquiries and/or transfer calls to appropriate party.
• Create and mail out acknowledgement letters and other member facing material.
• Follow up on request for responses, medical records, and denial packets with offices/providers/delegates if not recevied timely.
• Submit translation requests, comple and mail translations for grievance and appeals resolution letters.
• Review, log and coordinate expedited cases, will be responsible for sending expedited cases timely to clinical staff for review.
• Assist the Grievance and Appeal staff in initiation or completion of cases or projects and work with the Grievance and Appeal Lead to support day to day operations.
• Manage work in a confidential manner; ensuring information is shared with internal and external individuals as appropriate.
• Provide feedback to improve the member experience and identify girevance and appeals processing issues including escalating to leadership to address cross functional barriers and process gaps
• Assist in compiling files/documents for regulatory audits and familiarize self with NCQA, DMHC, DHCS, and NCQA regulations as they apply to position.
• Abide by grievance and appeals processes and regulatory requirements.
• Perform other duties and special projects as assigned.

ESSENTIAL FUNCTIONS OF THE JOB

• Coordinate grievance and appeal activities by receiving, handling, and resolving member issues and operational issues with other organizational staff;
• Operate general office equipment such as personal computer, copier, fax, and other office machines.
• Receive, manage, and document telephone calls, emails, and other sources of contacts from members, and providers, and explain health plan benefits and plan rules. Provide clarification about issues regarding patient and physician rights and how the plan operates.
• Create and/or mail appropriate member materials and communications as needed.
• Perform ongoing data entry which assists in the maintenance of the Grievance and Appeals department database to ensure data integrity.
• 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:

• Experience working in a call center, patient relations or other customer service position, required.

SPECIAL QUALIFICAITONS (SKILLS, ABILITIES, LICENSE):

• Knowledge of managed care and medical terminology;
• Experience in quality and utilization management systems;
• De-escalate challenging situations in which people may be upset;
• 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: $27.11- $40.66 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.