Appeals & Grievance Coordinator

Location: Remote-US, California US

Notice

This position is no longer open.

Job Number: 6102

Workplace Type: Fully Remote

Position Title: Appeals & Grievance Coordinator

External Description:

 

 

The Appeals & Grievance Coordinator is responsible for the day-to-day functions of the tracking and trending of all grievances, appeals, and complaints received within the Member Services Department. This position will also act as the primary investigator and contact person for both member and provider grievances and appeals.

Required Skills & Experience

  • Responsible for complex appeals and grievance cases; handling escalations appropriately
  • Will appropriately acknowledge the receipt of all grievance/appeals, and CTM (Complaint Tracking Module).
  • Responsible for the gathering of all pertinent and relevant information from the member and/or provider regarding the grievance/appeal, determining the appropriate resolution of the grievance/appeal per standard policies and procedures; and notifying the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.
  • Compose written correspondence to members in accordance to plan policy and CMS Guidelines.
  • Conduct non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal.
  • Thoroughly document all action taken on behalf of the member or provider to resolve the grievance/appeal.
  • Ensure that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy.
  • Prepare case files for Medical Director Review and external (including IRE) review of grievances/appeals as appropriate.
  • Prepare clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors).
  • Maintain accurate and timely documentation, including complete files of all grievances/appeals. Prepare monthly and quarterly reports as requested.
  • Identify training opportunities and potential system and process improvements relating to grievance/appeal data.
  • Participate in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements as well as participate in periodic CMS Audit preparations and regulator meetings/interviews.
  • Maintain a positive and professional relationship with CCHP staff, providers, members, and regulators.
  • Other duties as assigned.
  • Mathematical Skills:  Ability to add and subtract two-digit numbers and to multiply and divide with 10’s and 100’s.  Ability to perform these operations using units of American money and weight measurement, volume, and distance.
  • Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.  Ability to deal with problems involving a few concrete variables in standardized situations.
  • Computer Skills:  Strong computer skills.
  • Excellent communication skills.
  • Excellent written skills
  • Good telephone techniques.
  • Excellent data entry.
  • Strong organizational skills.
  • Type 40+ words per minute.
  • Experience with 10-key by touch.

Pay Range: $42,400.00 - $63,600.00 Annually

City: Remote-US

State: California

Location City: Remote-US

Location State: California

Community / Marketing Title: Appeals & Grievance Coordinator

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! 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, 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].