Grievance and Appeals Coordinator 23-01239 - Alura Workforce Solutions

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 COMPANY 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.

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 and the company
3. Ensure compliance with the Grievance and Appeals Resolution Process, in accordance with all Health Plan regulatory agencies.
4. Responsible for providing administrative support to ensure grievance and appeal cases are processed per regulatory guideline and internal department protocol including:
a. Coordinate, document and track all Member and Provider grievances and appeals.
b. Generates written correspondence to Providers, Members, and regulatory entities using appropriate grammar and punctuation.
c. Ensure all appropriate grievance and appeal letters are sent out within regulatory compliance guidelines.
d. Assist personnel in filing, tracking and closing Member and Provider grievances.
5. When designated to intake cases, the Grievance and Appeals Coordinator will ensure the following:
a. Assign new cases as received for medical urgency and assign to appropriate Grievance Team Member for investigation and resolution.
b. Alert assigned Team Member to any immediate needs, provide guidance regarding depth of investigation, best investigative approach, and manner of documentation, such as close oral case as a "1-day” (no written notification required), obtain verbal or written response from provider as indicated, or resolve internally with no provider input required.
6. Act as a liaison between departments to coordinate information and close grievances and appeals within regulatory timelines.
7. Keep the Grievance and Appeals Supervisor aware of "open” & "pending” grievance/appeal issues and expected resolution measures.
8. Maintain and prepare grievance and appeals summary reports, as needed.
9. Assist management in the assessment of grievance and appeal information for the potential change to policies and procedures.
10. Responsible for working with Team Members to support the protocols and goals of the department and the vision of the organization.
11. Demonstrate a commitment to incorporate LEAN principles into daily work.
12. Speak to health plan members as needed to clarify or obtain any information necessary in order to process a Grievance or an Appeal appropriately.
13. Speak to health plan members as needed to answer any questions regarding their case.

• 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.
• Experience in a managed care Member Service/Customer Service environment. Prior Medi-Cal and Medicare experience helpful. Previous experience documenting and resolving Member and Provider grievances and appeals.
• High school diploma or GED required.
• Bachelor's degree from an accredited institution preferred.
• Yes, must have a valid California Driver's License.

• Hybrid