Appeals & Grievance Coordinator

Summary

The Appeal & Grievance Coordinator is responsible for the receipt, investigation and processing of member grievances and appeals.

Essential Duties and Responsibilities

Essential duties and responsibilities include but are not limited to:

1. Responsible for the appropriate and accurate categorization of each request type (grievances, appeals, CTM, LEP) received.
2. Acknowledges receipt via outreach to member to inform of receipt and help set expectations on resolution timeframes.
3. Responsible for ensuring medical records requests and information needed to investigate the members’ concerns are followed up with and received timely.
4. Uses all tools and resources to conduct non-biased investigations of all the facts to determine the appropriate resolution per plan benefit coverage rules and department policy and procedures.
5. Creates written correspondence notices for members/authorized parties in accordance with plan policy.

1. Prepare clear, objective, accurate and comprehensive case histories for clinical /administrative review, including but not limited to IRE case submission.
2. Maintains accurate and timely documentation of all case interactions/actions

     taken in the plan’s database, including complete case files of all assigned

     workload.

1. Adheres to and maintains compliance with all processing timeframes according to

          company policy and in accordance with CMS guidelines.

1. Prepare monthly and quarterly reports as requested, ensures timely case  

          management of work assigned.

1. Answers all incoming calls from the Appeals & Grievance phone queue.

11.Participate in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements including but not limited to periodic CMS Audit preparations and regulator meetings/interviews.

1. Maintain a positive and professional relationship with plan staff, providers,

           members, and regulators.

1. Other duties as assigned.

Supervisory Responsibilities

None.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Education and/or Experience:  High school diploma or general education degree (GED)
2. Certificates, Licenses, Registrations:  None required.
3. Other Qualifications: 
1. Knowledge of Medi-Cal or Medicare Managed Care Plans.

1. Minimum of 3 years’ experience working in grievances and appeals, claims, or customer service; or any combination of education and experience which would provide an equivalent background

1. Bi-lingual (English/Spanish) preferred.

Skills and Abilities

1. 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.
2. 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.
3. 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.
4. Computer Skills:  Strong computer skills.
5. Other Skills and Abilities:
1. Excellent communication skills.

1. Excellent written skills

1. Critical thinker.
2. Excellent data entry.
3. Strong organizational skills.
4. Type 40+ words per minute.
5. Experience with 10-key by touch.