Common Spirit-posted about 1 month ago
Full-time • Entry Level
Hybrid • Rancho Cordova, CA
5,001-10,000 employees
Water Transportation

Position Summary: The Appeals and Grievances Coordinator is responsible for supporting the appeals department team members by managing and coordinating the appeals and grievance process. This role involves: facilitating delivery of member and provider complaints ensuring compliance with regulatory requirements facilitating timely and effective resolution of appeals and grievances. Acting a subject matter expert (SME), the Coordinator will work closely with internal teams and external stakeholders to ensure a high level of service and satisfaction. This position oversees a mix of operational, business and regulatory activities related to several Health Plan Partnerships. This position will work closely with health plan partners to ensure a seamless transition in implementing new and ongoing regulatory requirements. From a business perspective, this role is responsible for the ongoing delegation and performance of our contractual obligations with our Health Plan partners.

  • managing and coordinating the appeals and grievance process
  • facilitating delivery of member and provider complaints
  • ensuring compliance with regulatory requirements
  • facilitating timely and effective resolution of appeals and grievances
  • work closely with internal teams and external stakeholders to ensure a high level of service and satisfaction
  • work closely with health plan partners to ensure a seamless transition in implementing new and ongoing regulatory requirements
  • responsible for the ongoing delegation and performance of our contractual obligations with our Health Plan partners
  • 2+ years administrative experience in a compliance auditing arena. Previous experience in a similar administrative or coordination role.
  • Associates degree or 3 years of related job or industry experience in lieu of degree
  • Familiarity with healthcare regulations, including HIPAA, CMS, and state-specific requirements
  • 2 years managed care experience preferred
  • 1 year delegation oversight experience preferred
  • Regulatory audit experience preferred
  • Bachelors degree or 5 years of related job or industry experience in lieu of degree preferred
  • Certified Compliance Professional (CCP) Certified Professional in Healthcare Quality (CPQH) Certified Healthcare Auditor (CHA) preferred
  • Knowledge of DMHC, NCQA, CMS and other regulatory bodies preferred
  • Knowledge of HIPPA, managed care environment preferred
  • Strong technical proficiency in data analysis; database software preferred
  • Familiarity with compliance requirements is a plus
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