Appeals & Grievance Coordinator

Alignment Health

About The Position

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together. 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. Acts as the primary investigator and contact person for member and provider grievances and appeals.

Requirements

Two years’ experience in data entry and general office background.
Three years of customer service experience.
Minimum 1 year Member Services or similar experience.
High School Diploma or GED.
Ability to Keyboard/Type 40+ words per minute and use the 10-key by touch.
Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors
Ability 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.
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.
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.
Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
Knowledge of MediCal and Medicare Managed Care Plans.

Nice To Haves

2 years healthcare or insurance experience in a senior setting.
Associate degree (A.A.) degree.
Bi-lingual (English/Spanish)

Responsibilities

Acknowledges the receipt of all grievance/appeals, and CTM (Complaint Tracking Module).
Gathers pertinent and relevant information from the member and/or provider regarding the grievance/appeal, determines the appropriate resolution of the grievance/appeal per standard policies and procedures; and notifies the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.
Composes written correspondence to members in accordance to plan policy and CMS Guidelines.
Conducts non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal.
Thoroughly documents all action taken on behalf of the member or provider to resolve the grievance/appeal.
Ensures that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy.
Prepares case files for Medical Director Review and external (including IRE) review of grievances/appeals as appropriate.
Prepares clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors).
Maintains accurate and timely documentation, including complete files of all grievances/appeals. Prepares monthly and quarterly reports as requested.
Identifies training opportunities and potential system and process improvements relating to grievance/appeal data.
Participates 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.
Other duties as assigned.