Appeals & Grievances Coordinator II

MedImpact Healthcare Systems, Inc.•San Diego, CA

8d•$20 - $31•Onsite

About The Position

The Appeals & 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 & Grievances Coordinator II 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 & Grievances Operations and is led by the Lead Coordinator (Coordinator III). The Coordinator II utilizes various business applications—such as MedAccess, MedResponse®, FileNet, RightFax, and Salesforce—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. General knowledge of Microsoft Excel is required to assist in managing and generating reports related to appeals and grievances metrics. The ability to multitask and cross-train in both appeals and grievances processing is essential to support the weekend rotation schedule. Additional responsibilities include assisting the Lead Coordinator (Coordinator III) in training new employees and interacting with both internal and external customers as needed.

Requirements

GED/HS Diploma and 2+ years’ experience or equivalent combination of education and experience.
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.
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.
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 read and comprehend simple instructions, short correspondence, and memos.
Ability to write simple correspondence.
Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public.
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
Regularly required to sit and talk or hear.
Regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms.
Must occasionally lift and/or move up to 25 pounds.

Nice To Haves

Previous Pharmacy Benefit Management experience preferred.
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.
Assisting management with the quality review program.
Must be able to cross-train across the appeal and grievance task divisions.
Managing and generating reports for appeals and grievances metrics.
Assisting Appeals and Grievances Coordinator III with staff process training.
Participating in the rotating weekend on-call schedule as needed.