Coordinator - Grievance and Appeals

Impresiv Health•Rancho Cucamonga, CA

About The Position

Impresiv Health is seeking a Grievance and Appeals Coordinator to support the administrative functions and daily activities associated with processing member and provider grievances and appeals for a health plan organization. Under the general direction of Grievance and Appeals leadership, this position is responsible for coordinating, documenting, tracking, and supporting grievance and appeal cases while ensuring compliance with established regulatory requirements, departmental procedures, and applicable health plan guidelines. The Grievance and Appeals Coordinator will use independent judgment to identify potential issues, escalate trends or deficiencies when appropriate, and support the timely resolution of member and provider cases. This position also supports organizational quality initiatives, including programs and standards related to HEDIS, CAHPS, and NCQA Accreditation.

Requirements

High School Diploma or GED
Bilingual English/Spanish verbal and written communication skills.
3+ years of administrative experience in an office environment.
Experience using Microsoft Office applications.
Experience working in a managed care Member Services or Customer Service environment.
Previous experience documenting and resolving member and provider grievances and appeals.
Strong written and verbal communication skills.
Strong interpersonal and administrative skills.
Strong organizational and time-management skills.
Ability to type at least 45 words per minute.
Proficiency with Microsoft Word and Excel.
Data entry experience.
Strong telephone communication and customer service skills.
Ability to handle multiple priorities simultaneously.
Strong attention to detail and the ability to prioritize work according to deadlines.
Ability to learn and consistently follow established standards and procedures.
Ability to work independently while contributing effectively within a team environment.

Nice To Haves

Prior Medi-Cal experience.
Prior Medicare experience.
Bachelor’s degree from an accredited institution.

Responsibilities

Maintain a working knowledge of regulatory requirements and guidelines related to grievances and appeals, including CMS, DHCS, and DMHC requirements.
Understand member and provider rights regarding access to the grievance and appeals resolution process.
Support compliance with grievance and appeals processes in accordance with applicable health plan regulatory agencies.
Coordinate, document, and track member and provider grievances and appeals.
Provide administrative support to ensure grievance and appeal cases are processed according to regulatory requirements and internal departmental protocols.
Generate written correspondence to members, providers, and regulatory entities using appropriate grammar, punctuation, and professional communication standards.
Ensure required grievance and appeal correspondence is distributed within established regulatory timelines.
Assist internal teams with filing, tracking, documenting, and closing member and provider grievances.
Review and intake new cases when assigned and route cases for medical urgency review and appropriate investigation.
Identify immediate case needs and communicate them to the appropriate team member.
Support the determination of the appropriate investigative approach, documentation requirements, and provider involvement based on case circumstances and established procedures.
Serve as a liaison between internal departments to obtain necessary information and support the timely resolution of grievances and appeals.
Monitor open and pending grievance and appeal cases and communicate unresolved issues and expected resolution activities to department leadership.
Prepare grievance and appeals reports and summaries as requested.
Assist management with reviewing grievance and appeal information to identify opportunities for improvements to policies, procedures, and operational processes.
Collaborate with team members to support departmental protocols, performance goals, and organizational objectives.
Incorporate LEAN principles into daily work and process improvement activities.
Communicate directly with health plan members when necessary to clarify information required to appropriately process a grievance or appeal.
Respond to member questions regarding the status or processing of their grievance or appeal.
Maintain a strong focus on regulatory compliance, accuracy, timeliness, and customer service.