Grievance and Appeals Call Center

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  • 19-00497
  • Full Time/Contract
  • Recruiting
  • Rancho Cucamonga, CA
Job Description

Grievance and Appeals 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 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
1. Maintain working knowledge of regulatory guidelines of grievances and appeals per CMS, DMHC, and DHCS.
2. Understand Member and provider legal rights to access the grievance resolution process, within the respective Provider Organization and IEHP.
3. Responsible for facilitating call center operations per department protocols including:
a. Communicating with Members, providing information and assistance over the telephone.
b. 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.
c. Maintaining standards for Members rights and responsibilities, such as confidentiality.
d. Maintaining call handling in compliance with regulatory provisions.
e. Timely recording and forwarding of grievances and appeals to the Grievance & Appeal staff.
f. Documenting timely and accurate of all calls received. Over 100% call documentation is required.
g. Performing Member satisfaction and needs assessment surveys, as needed.
h. Preserving Member’s confidentiality by authenticating callers (verify guardianship documents, establish guardianship alerts, as needed).
i. Timely follow up with Members or providers on cases as needed.
j. Coordinating telephonic translation of calls when Members do not speak English or Spanish
k. Coordinate communication through the TTY system (telephone device used by people who are deaf or hard of hearing).
l. Act as a liaison between IEHP departments to coordinate information and close grievances within regulatory time frames.
4. Meet IEHP 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 IEHP equipment appropriately and for professional reasons only, following required call scripts, following IEHP Attendance policy and follow-up and timely resolution of pending cases.
5. Strict adherence to specific work schedule is required.
6. Responsible for Member advocacy regarding obtaining benefits, accessing care, referrals and medication status, etc. Successful knowledge of all IEHP product lines and ability to transfer knowledge to all callers’ inquiries.
7. Present cases to Grievance & Appeals Management Team and work with other departments when resolving Member and provider issues.
8. Demonstrate a commitment to incorporate LEAN principles into daily work.


A minimum of 1-year call center experience. (May substitute with 2 years of experience in a medical setting.) Microsoft Windows applications experience. Significant customer service experience with prior experience in handling and resolving problems and complaints with a high degree of patience.
1-year call center experience in a customer services setting preferred. Medi-Cal and Medicare program and benefit requirements experience desired. HMO or Managed Care Experience preferred.
High school diploma or GED required.



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