Grievance Coordinator

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  • 17-00201
  • Full Time/Contract
  • Customer Service
  • Rancho Cucamonga, CA
Job Description
CLIENT COMPANY OVERVIEW

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.

JOB TITLE
Appeals & Grievances Coordinator

POSITION SUMMARY
Responsible for providing excellent customer service and detailed research for each member case in accordance with established policies and procedures. Manages appeal&grievance activities such as documentation, research, and written/verbal functions. Complies with all regulations ensuring timeliness of all cases. Maintains organization to ensure accurate accounting of all Grievance files.

  • Maintain working knowledge of regulatory guidelines surrounding Grievances per CMS, DHCS, and DMHC.
  • Understand Member and Provider legal rights to access the grievance resolution process, within the respective Provider Organization and IEHP.
  • Ensure compliance with the Grievance Resolution, in accordance with all Health Plan regulatory agencies.
  • Responsible for providing administrative support to ensure grievance cases are processed per regulatory guideline and internal department protocol including:
    • Coordinate, document and track all IEHP Member and Provider grievances. Ensure grievance reports are distributed to all appropriate departments in established time frames.
    • Generates written correspondence to Providers, Members, and regulatory entities using appropriate grammar and punctuation.
    • Ensure all appropriate grievance letters are sent out within regulatory compliance guidelines.
    • Assist IEHP personnel in filing, tracking and closing member and provider grievances.
  • Act as a liaison between IEHP departments to coordinate information and close grievances within regulatory timelines.
  • Keep the Grievance Supervisor and IEHP management aware of "open & "pending grievance issues and expected resolution measures.
  • Maintain and prepare grievance summary reports, as needed.
  • Understand Member and Provider legal rights to access the grievance resolution process, within the respective Provider Organization and IEHP.
  • Assist IEHP management in the assessment of grievance information for the potential change to IEHP policies and procedures.
  • Any other duties as required to ensure the Health Plan operations are successful.
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in IEHP’s policies and procedures relating to HIPAA compliance

QUALIFICATIONS
Member Services / Appeals & Grievance Experience

  • Managed Care Health Plan / IPA experience
  • – Bilingual (English/Spanish) preferred
  • – Knowledge of Medicare and Medi-Cal guidelines
  • – Excellent Customer Services Skills
  • – Superb Problem Resolution Skills
  • – Excellent time management, organization and communication skills

COMPENSATION | POSITION CLASSIFICATION
Full Time | Direct Hire
$16.00/HR – 18.00/HR


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