Appeals and Grievance Coordinator- Bakersfield 1.1

Universal Healthcare MSO•Bakersfield, CA

4d•Onsite

About The Position

The Appeals and Grievance Coordinator supports the end-to-end appeals and grievances process, including intake, tracking, and resolution of member and provider complaints and appeals. The role handles low-complexity cases and administrative tasks such as organizing case documentation, monitoring deadlines, and ensuring timely follow-up. The coordinator works with internal departments to resolve issues involving member eligibility, benefits, claims, utilization management, and pharmacy decisions. The position also participates in training sessions and cross-functional work groups to improve operational efficiency and service quality. This is a full-time, non-exempt hourly position based onsite in Bakersfield, California. Universal Healthcare MSO’s standard operating hours are Monday through Friday, 8:00 a.m. to 5:00 p.m. Pacific Time; employees are expected to work their assigned schedules and remain available during those hours unless otherwise specified.

Requirements

One year of experience in a managed healthcare setting, health plan, or provider office.
Experience interacting with members, patients, and/or providers and receiving complaints, preferably related to healthcare administration.
Working knowledge of customer service principles and practices.
Working knowledge of managed healthcare, healthcare coverage and benefit structures, coordination of benefits, and medical billing.
Working knowledge of and proficiency in Microsoft Word, Outlook, Adobe Acrobat, and Excel.
Practical understanding of research methods, analysis techniques, and reporting processes.
Ability to conduct confidential and sensitive telephone interviews effectively.
Working knowledge of conflict resolution techniques.
Ability to address sensitive or challenging issues with tact and diplomacy.
Proficiency in listening, de-escalation techniques, and critical thinking skills.

Nice To Haves

Associate’s degree in health, social services, or a related healthcare field, or equivalent work experience in related healthcare.
Bilingual in English and Spanish.

Responsibilities

Support process improvements, system enhancement testing, new process implementations, and documentation of adjustments as requested.
Maintain appeal and grievance data and tracking mechanisms, and process case requests to support regulatory, internal, external, and audit requirements.
Receive, open, track, and route appeal and grievance mail, faxes, email, voicemail, and case correspondence.
Review appeal and grievance correspondence and case requests.
Create cases in the health plan appeals and grievances tracking application and scan documentation when applicable.
Intake, enter, track, and update State Fair Hearing notices; inform assigned grievance staff of updates and provide administrative support during scheduled hearings.
Track appeal requests to Livanta BFCC-QIO, an independent reviewer, to extend health plan member covered services.
Respond to member and provider inquiries and requests by phone, fax, web, and written correspondence.
Attend Grievance and Appeals Committee meetings and prepare and present agenda items as approved or assigned by leadership.
Attend monthly department meetings and prepare and present agenda items as assigned by leadership.
Participate in cross-departmental work groups, grievance system trainings, and initiative meetings as assigned.
Share information from work groups and initiatives with the Grievance/Appeal Team during weekly team meetings.
Perform other duties as assigned.