Grievance Coordinator

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  • 18-00202
  • Full Time/Contract
  • Recruiting
  • 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.

POSITION TITLE

GRIEVANCE COORDINATOR

JOB SUMMARY
Under the general direction of the Grievance & Appeals Nurse Manager and Grievance Supervisor, the Grievance Coordinator is responsible for completing administrative functions and supporting departmental activities for processing Grievance cases. The Grievance Coordinator is responsible for ensuring that Company personnel adhere to the guidelines established and outlined in the Company Grievance Resolution System. The Grievance Coordinator exercises independent judgment to ensure appropriate escalation protocols when trends or deficiencies are identified.

REQUIREMENTS

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

MINIMUM QUALIFICATIONS

Education/License: Possession of a high school diploma or equivalent. Bachelor’s degree preferred. Possession of a valid California Driver’s license and valid Automobile insurance.
Experience: Three or more (3+) years of administrative experience in an office environment, including use of Microsoft Office Suite Minimum of two (2) years’ experience in a managed care Member Service/Customer Service environment preferred. Prior Medi-Cal and Medicare experience helpful. Previous experience documenting and resolving Member and Provider grievances and appeals. Bilingual written and verbal preferred.. Demonstrate superior interpersonal and administrative skills commensurate with years of experience.
Knowledge/Skills Required: Excellent communication and interpersonal skills. Understanding of and sensitivity to multi-cultural community. Strong organizational skills, typing 45 words per minute, proficient in Microsoft Word and Excel, telephone courtesy, and data entry experience are essential. Ability to handle multiple tasks. Excellent communication and interpersonal skills. Strong attention to detail and ability to prioritize work to ensure adherence to task deadlines. Ability to learn and follow standards and procedures. Positive Attitude and ability to work in a team setting.

HOURS & COMPENSATION
Monday Friday; Days
$16.41/hr.

POSITION CLASSIFICATION
Full Time, Contract


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