Grievance and Appeals Coordinator – Call Center

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  • 18-00160
  • Full Time/Contract
  • Appeals & Grievances
  • Rancho Cucamonga, CA
Job Description
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company To Work For , "Favorite Training Program , and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.

Grievance and Appeals Coordinator Call Center

Under the direction of the Grievance & Appeals Call Center Manager, the Grievance & Appeals Call Center Coordinator is responsible for receiving, recording, and responding to Members’ and providers’ grievances in a friendly and professional manner. The Grievance and Appeals Call Center Coordinator is responsible for ensuring that call center operations activities are implemented per to guidelines established and outlined in the Healthplan’s Grievance and Appeal Resolution System. The Grievance and Appeals Call Center Coordinator exercises independent judgment to ensure appropriate escalation protocols when issues, trends, or deficiencies are identified


  • Maintain working knowledge of regulatory guidelines of grievances and appeals per CMS, DMHC, and DHCS.
  • Understand Member and provider legal rights to access the grievance resolution process, within the respective Provider Organization and Company.
  • Responsible for facilitating call center operations per department protocols including:
  • Communicating with Members, providing information and assistance over the telephone.
  • Provide excellent customer service to all callers. This includes, but is not limited to the following; demonstrating a high level of patience and respect with every caller, avoiding distractions to ensure each caller is assisted promptly and appropriately and following Grievance & Appeals Call Center established call handle standards and objectives.
  • Maintaining standards for Members rights and responsibilities, such as confidentiality.
  • Maintaining call handling in compliance with regulatory provisions.
  • Timely recording and forwarding of grievances and appeals to the Grievance & Appeal staff.
  • Documenting timely and accurate of all calls received. Over 100% call documentation is required.
  • Performing Member satisfaction and needs assessment surveys, as needed.
  • Preserving Member’s confidentiality by authenticating callers (verify guardianship documents, establish guardianship alerts, as needed).
  • Timely follow up with Members or providers on cases as needed.
  • Coordinating telephonic translation of calls when Members do not speak English or Spanish
  • Coordinate communication through the TTY system (telephone device used by people who are deaf or hard of hearing).
  • Act as a liaison between Healthplan departments to coordinate information and close grievances within regulatory time frames.
  • Meet Healthplan and Grievance & Appeals Call Center standards and policies requirements. This includes, but is not limited to the following; successful completion of Grievance & Appeals training, active participation in continuous training, answer all calls within two (2) rings, use telephone system and other company equipment appropriately and for professional reasons only, following required call scripts, following company Attendance policy and follow-up and timely resolution of pending cases.
  • Strict adherence to specific work schedule is required.
  • Responsible for Member advocacy regarding obtaining benefits, accessing care, referrals and medication status, etc. Successful knowledge of all company product lines and ability to transfer knowledge to all callers’ inquiries.
  • Present cases to Grievance & Appeals Management Team and work with other departments when resolving Member and provider issues.
  • Demonstrate a commitment to incorporate LEAN principles into daily work
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in company’s policies and procedures relating to HIPAA compliance.
  • Any other duties as required to ensure the Health Plan operations are successful


  • High School Diploma or GED required
  • Bilingual Spanish Required
  • Medi-Cal and Medicare program and benefit requirements experience desired. HMO or Managed Care Experience preferred.
  • A minimum of 1 year call center experience in a customer services setting preferred. May substitute with 2 years of experience in a medical setting. Microsoft Windows applications experience.
  • Candidate must feel comfortable with learning and using computer programs.
  • Typing- Minimum 35 wpm, good grammar and spelling skills are necessary.
  • Excellent punctuality and attendance is required.
  • Significant customer service experience with prior experience in handling and resolving problems and complaints with a high degree of patience. Ability to remain courteous when dealing with difficult or challenging callers is critical to this position. Ability to learn and follow standards and procedures.

Full Time | Contract Assignment


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