Appeals & Grievance Coordinator

Location: Remote-US, California US

Notice

This position is no longer open.

Job Number: 5012

Workplace Type: Fully Remote

Position Title: Appeals & Grievance Coordinator

External Description:

The Grievance and Appeals Coordinator is responsible for receiving, researching and resolving of new and existing member and provider grievance and appeals cases. These cases MAY including escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements.


Essential Duties and Responsibilities

To perform this job successfully, an individual must be able to perform each:

  • Ensure grievance and appeals cases are accurate and include the necessary elements for processing and resolving, giving special attention to those identified as “Expedite”. Create clear and concise documentation in applicable system(s).
  •  Identify all issues and required actions within a case, appropriately categorize cases and identify required actions in accordance with state and federal regulations.
  • Create and manage  documents, correspondence and reports in a manner that meets required timeframes.
  • Ensure adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required timeframes.
  • Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing.
  • Contact members and providers to seek additional information or clarification regarding grievance and appeals cases and review and resolve issues by requesting medical records, notice of action, or any other pertinent information related to grievances and appeals from medical groups, delegated entities and/or providers.
  • Perform complete, accurate and consistent data entry into system software applications in accordance with policies, procedures and instruction from the Manager of Grievance and Appeals Operations.
  • Assist the Manager of Grievance and Appeals Operations and peers with special projects. Work collaboratively and cross-functionally with other departments to facilitate appropriate resolutions. Work as a team to complete departmental tasks to meet deadlines and accomplish department objectives.
  • Perform other related duties as required or assigned.

 

Supervisory Responsibilities

None

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  1. Education and/or Experience:  High school diploma or general education degree (GED)
  2. Certificates, Licenses, Registrations:  None required.
  3. Other Qualifications: 
    1. Knowledge of Medi-Cal or Medicare Managed Care Plans.
    2. Three to five years customer service experience.
    3. Two to three years of Appeals & Grievance preferred.
    4. Bi-lingual (English/Spanish) preferred.

Skills and Abilities

  1. Language Skills:  Able to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals.  Ability to write routine reports and correspondence.  Ability to speak effectively before groups of customers or employees of the organization.
  2. Mathematical Skills:  Able to add and subtract two-digit numbers and to multiply and divide with 10’s and 100’s.  Able to perform these operations using units of American money and weight measurement, volume, and distance.
  3. Reasoning Skills:  Able to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.  Able to deal with problems involving a few concrete variables in standardized situations.
  4. Computer Skills:  Strong computer skills.
  5. Other Skills and Abilities:
    1. Excellent written and verbal communication skills                    
    2. Excellent telephone techniques.
    3. Excellent data entry.
    4. Strong organizational skills.
    5. Able to type minimum 40+ words per minute.
    6. Able to type using 10-key by touch. 

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  1. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
  2. The employee is frequently required to walk; stand; reach with hands and arms.
  3. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
  4. The employee must occasionally lift and/or move up to 20 pounds.
  5. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  1. The noise level in the work environment is usually moderate.

 

City: Remote-US

State: California

Location City: Remote-US

Location State: California

Community / Marketing Title: Appeals & Grievance Coordinator

Company Profile:

Alignment Health is revolutionizing health care for seniors by leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].