Appeals & Grievances Coordinator I

MedImpact Healthcare Systems, Inc.•San Diego, CA

45d•$18 - $28•Onsite

About The Position

The Appeals and Grievances (A&G) team is responsible for managing all aspects of the appeals and grievances process, including—but not limited to—intake, processing, notification, and compliance. The Appeals and Grievances Coordinator I serves as a key member of the A&G team, processing appeal and grievance requests in accordance with established standards for accuracy, timeliness, productivity, client performance commitments, and regulatory requirements (e.g., state and federal regulations, professional accreditations). This position reports directly to the Supervisor of Appeals and Grievances Operations and is led by the Lead Coordinator (Coordinator III). The Coordinator I utilizes various business applications—such as MedAccess, MedResponse®, FileNet and RightFax - to perform analysis, retrieve information, and enter data as needed to complete assigned tasks. Strong reasoning skills are essential for evaluating appeal and grievance requests for appropriateness and ensuring adherence to required processes. The ability to multitask and cross-train in both appeals and grievances processing is essential to support the weekend rotation schedule. Interact with internal and external customers as required. Work under general supervision, relying on work instructions, policies & procedures, and available company resources to perform the functions of the position efficiently and effectively.

Requirements

GED/HS Diploma and 1+ year experience or equivalent combination of education and experience
To perform this job successfully, an individual should have knowledge of MS Office Suite.
Proficiency of knowledge of Microsoft Word and Microsoft Excel.
Certified Pharmacy Technician and/or state licensure as a Pharmacy Technician required.
Oral Communication: Speak clearly and persuasively in positive or negative situations. Listen and obtain clarification when needed. Responds well to questions.
Written Communication: Write clearly and informatively. Edit work for spelling and grammar.
Teamwork: Balance team and individual responsibilities. Exhibit objectivity and openness to others' views. Give and welcome feedback. Contribute to building a positive team spirit. Put the success of the team above own interests. Support everyone’s efforts to succeed.
Organizational Support: Follow policies and procedures. Complete required tasks correctly and on time. Support organization's goals and values. Benefit organization through outside activities. Support affirmative action and respect diversity.
Reasoning Ability 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.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Mathematical Skills Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
Language Skills Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence. Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.
Composure
Decision Quality
Organizational Agility
Problem Solving
Customer Focus
Drive for Results
Peer Relations
Time Management
Dealing with Ambiguity
Learning on the Fly
Political Savvy

Nice To Haves

Certified Pharmacy Technician Certification preferred.

Responsibilities

Evaluate and process Appeals and Grievances per establish work instructions and approved departmental documents.
Perform and document outreach activities (including outbound calls and faxes) to obtain information necessary for processing Appeals and Grievances or to communicate the results of Appeal and Grievance reviews.
Ensure Appeals and Grievances are finalized within the required turnaround time (TAT) in accordance with applicable laws and company policies.
Must be able to cross-train across the appeal and grievance task divisions.
Participating in the rotating weekend on-call schedule as needed.
Protect and maintain confidentiality and privacy of all members’ personal and health information in accordance with federal requirements and company policies.
Must comply with company and department policies, procedures, rules and regulations.
Must possess the ability to adapt to departmental changes as required for the needs of the business.
Must be flexible with shift changes.