- Direct Placement
- Monterey Park, CA
Our client is a Managed Care Health Plan committed to providing health care that is medically excellent, ethically driven and delivered in a patient-centered environment that recognizes the positive relationship between health education, a culture of wellness, an emphasis on prevention and a cost-effective delivery of care.
Appeals & Grievance Coordinator
Under minimal supervision, provides and is responsible for, in accordance with established policies and procedures, the research and documentation of written and verbal complaints and appeals filed by members, providers and external agencies. The Coordinator is responsible for identifying issues, grievances, and appeals to categorize and enter information into the database, creating an individual file folder. The supporting documents and data are entered for resolving the issue and corresponding with the party according to regulatory requirements.
Responsible for the handling of assigned appeals and grievances by inputting into appropriate databases, writing acknowledgement letters, obtaining medical records as needed, researching cases, resolving issues and mailing and faxing resolution letters and ensuring time frames are met for acknowledgement and resolution letters. Must comply with all regulatory requirements and policies of Health Plan.
- Works with the CMO and the Medical Directors, who oversee clinical aspects of the department, to ensure that the clinical issues are appropriately evaluated.
- Answers telephone inquiries and maintains a professional level of telephone etiquette.
- Responds to any questions from members, family members, authorized representatives, providers and others regarding appeals and grievances.
- Processes, researches and responds to members, providers and other external agency inquiries regarding appeals and grievances received by phone, fax or mail in accordance with policies and procedures and regulatory guidelines and procedures.
- Responsible for investigating and resolving all priority issues and/or concerns in a timely and efficient manner. These issues require immediate attention due to the nature of the concern.
- Works closely with internal departments to resolve and research member and provider reconsideration, contacts members, providers and external agencies to obtain additional information to adequately resolve and respond to the reconsiderations and grievances.
- Assists as needed in investigating member claims or billing discrepancies and coordinates with Claims Department in order to successfully achieve corrective actions and resolution.
- Maintains departmental filing system for accessible and complete appeal and grievance files involving confidential information ensuring accurate and timely handling.
- Contacts members, providers and external agencies to obtain additional information to adequately resolve and respond to reconsidera
- Maintains confidentiality of patient information, meets indentified productivity and quality of work standards on an ongoing basis.
- Demonstrates an understanding of the functions of other departments and affiliates while communicating appropriately to maintain positive working relationships. Supports department in administrative, data management and clerical duties.
- Responsible for addressing and forwarding quality of care complaints to quality management for resolution and/or assisting in investigation in conjunction with quality management medical review.
- Responsible for addressing and forwarding fraud and abuse/sales allegations to the Compliance Department for resolution and/or assisting in the investigation in conjunction with the quality management medical review.
- Participates in regular meetings to review case logs, CSIM logs and reported codes and other issues regarding the Appeals & Grievance Department.
- Responsible for formulating/implementing and executing all processes, requests, workflows or policies as requested by management in a courteous and efficient manner, including offering a proactive approach to suggestions and recommendations and working or cooperating with all office associates and management.
- Must be able to accomplish duties and assignments with minimal supervision.
- Act as a liaison to all company departments as necessary.
- Minimum High School Diploma or GED
- Previous experience in appeals and grievance, utilization management,
or member services
- Ability to successfully interact with members, physicians, medical representatives
and other medical professionals, health plan and governmental representatives
- Excellent organizational skills and ability to handle multiple tasks
- Excellent verbal and written communication skills
- Excellent proficiency in Excel, Word and Access
- Attention to detail and accuracy and capability of meeting deadlines consistently
- Ability to consistently work in a fast pace environment
COMPENSATION & BENEFITS