Grievance and Appeals Coordinator I

Health Plan of San Mateo • South San Francisco, CA

1d • Onsite

About The Position

Implement HPSM’s Grievance and Appeals processes by resolving complaints filed by HPSM members and their representatives as well as provide back-up support to Member Services and CareAdvantage units.

Requirements

• Work in a call center, claims department, and/or other customer service position required.
• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
• Work cooperatively with others.
• Work as part of a team and support team decisions.
• Communicate effectively, both verbally and in writing.
• Adapt to changes in requirements/priorities for daily and specialized tasks.
• Communicate effectively and professionally, both verbally and in writing.
• Summarize information clearly, thoroughly, and quickly in writing.
• Deal with difficult people and situations while providing quality customer service.
• Use sound judgment, identify next steps to be taken and develop appropriate solutions.
• Collaborate with multiple parties to solve problems; solve problems independently.

Nice To Haves

• Associate’s degree in health, business, social sciences, or humanities, preferred.
• Two (2) years of experience working with Medi-Cal or Medicare in a managed care environment preferred.
• Work performing grievance and appeals processing preferred.
• Medicare, Medi-Cal, Managed Care and medical terminology preferred.

Responsibilities

• Research and resolve member complaints for all lines of business ensuring compliance with HPSM’s Grievance and Appeals policies and procedures.
• Maintain grievance and appeals case files in HPSM’s database.
• Effectively communicate with members and providers verbally and in writing.
• Prepare summaries and write resolution letters for members, which include summarizing member complaints and steps taken to resolve complaints in clear and grammatically correct language.
• Attend and present cases at bi-weekly Staff Grievance and Appeals Committee.
• Prepare files for appeals to regulatory agencies.
• Maintain current on all regulatory requirements as they apply to grievance and appeal processes.
• May, as needed, provide necessary coverage in the call centers for Member Services and CareAdvantage.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree