Appeals and Grievances Coordinator

CommonSpirit Health • Rancho Cordova, CA

1d • Hybrid

About The Position

As our Appeals and Grievances Coordinator, you will expertly manage and resolve complex patient appeals and grievances, applying clinical expertise to ensure fair, timely, and compliant resolutions. Your critical role upholds patient rights, maintains regulatory compliance, and significantly contributes to patient satisfaction and organizational integrity. Every day you will thoroughly investigate patient issues using medical records and policy, communicating complex information clearly to all stakeholders while preparing detailed documentation for decisions. You'll ensure adherence to regulations, identify trends, and participate in quality improvement to prevent future problems. To succeed, you'll need exceptional clinical assessment and critical thinking, a comprehensive understanding of healthcare regulations, and excellent communication for sensitive conversations. A profound commitment to patient advocacy, fairness, and upholding ethical standards, along with self-motivation and adaptability, are essential in this demanding and evolving role.

Requirements

• 2+ years administrative experience in a compliance auditing arena
• 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.

Nice To Haves

• 2 years managed care experience preferred.
• 1 year delegation oversight experience preferred.
• Regulatory audit experience preferred.
• Bachelors degree in a relevant field (e.g., healthcare management, business administration, compliance) or 5 years of related job or industry experience in lieu of degree preferred.
• Certified Compliance Professional (CCP), Certified Professional in Healthcare Quality (CPQH), or Certified Healthcare Auditor (CHA) preferred.
• Knowledge of DMHC, NCQA, and other regulatory bodies preferred.
• Knowledge of managed care environment preferred.
• Strong technical proficiency in data analysis; database software preferred.
• Familiarity with compliance requirements is a plus.

Responsibilities

• Receive, document, and manage member and provider appeals and grievances according to organizational policies and regulatory standards.
• Assist team to ensure all cases are processed within required timeframes and follow-up actions are completed properly, as well as to maintain detailed and accurate records of all appeals and grievances, including documentation of investigations, outcome, and communications.
• Manages and works closely with Regulatory partners in the management of identified patient populations. Oversees a mix of operational, clinical, educational and business activities as they relate to this partnership.
• Prepare files as directed for appeals to regulatory agencies, staying current with all applicable regulatory requirements.
• Conducts relevant research into complaints and collaborates, coordinates and communicates with various departments (i.e. Member Services, Care Management, Claims), as well as external entities (i.e. Providers and Vendors) to collect additional information as necessary.
• Monitor and analyze trends in appeals and grievances to identify systemic issues and recommend corrective actions.
• Prepare and submit regular reporting on appeals and grievance activity, trends, and outcomes to management and regulatory agencies as required.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree
• Number of Employees: 5,001-10,000 employees