Appeals & Grievance Coordinator

GENERAL DUTIES/RESPONSIBILITIES: -Acknowledges the receipt of all grievance/appeals, and CTM (Complaint Tracking Module). -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.

-Composes written correspondence to members in accordance to plan policy and CMS Guidelines. -Conducts non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal. -Thoroughly documents all action taken on behalf of the member or provider to resolve the grievance/appeal.

-Ensures that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy. -Prepares case files for Medical Director Review and external (including IRE) review of grievances/appeals as appropriate. -Prepares clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors).

-Maintains accurate and timely documentation, including complete files of all grievances/appeals. Prepares monthly and quarterly reports as requested. -Identifies training opportunities and potential system and process improvements relating to grievance/appeal data. -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. Job Requirements: Required: 2 years’ experience in data entry and general office background. -3 years of customer service experience. Minimum 1 year Member Services or similar experience. Preferred: 2 years healthcare or insurance experience in a senior setting. Specialized Skills: Required: -Knowledge of Medi-Cal 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.