Grievance and Appeals Coordinator

Santaclara Family Health Plan•San Jose, CA

45d

About The Position

The Grievance and Appeals Coordinator is responsible for the beginning-to-end process of receiving, researching and resolving of new and existing member and provider grievance and appeals cases for all lines-of-business including any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and SCFHP policies and procedures as set forth for each line of business.

Requirements

High School diploma or GED. (R)
Minimum two years of experience in customer service, provider service, health service, or pharmacy in a managed care or health care environment handling escalated or complex issues. (R)
Knowledge of health plan benefits, processes and operations. (R)
Prior experience with commercial, Medi-Cal and/or Medicare programs and working with the underserved populations. (R)
Work weekends and company holidays as needed based on business regulatory requirements. (R)
Detail-oriented with the ability to conduct research and identify steps required to resolve issues and follow through to effectuation.(R)
Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the Grievance and Appeals Department operations as dictated by business needs (R)
Ability to consistently meet grievance and appeals accuracy and timeline requirements by achieving regulatory standards. (R)
Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel. (R)
Ability to use keyboard with moderate speed and a high level of accuracy. (R)
Excellent communications skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, Members, Providers and outside entities over the telephone, in person or in writing. The ability to remain calm and de-escalate tense situations. (R)
Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
Ability to maintain confidentiality. (R)
Ability to comply with all SCFHP policies and procedures. (R)
Ability to perform the job safely with respect to others, to property and to individual safety. (R)
Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment; (R)
Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

Nice To Haves

Associate's degree or equivalent experience, training or coursework. (D)
Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D)

Responsibilities

Act as a back-up to the Grievance and Appeals Intake Specialist during times of high volume work and/or staffing shortages to ensure appropriate intake of new and existing grievance and appeal cases, assessing the priority of each case and routing to the appropriate staff.
Ensure grievance and appeals cases are accurate and include the necessary elements for processing and resolving, giving special attention to those identified as "Expedite". Create clear and concise documentation in applicable system(s).
Use good judgment and department resources to identify all issues and required actions within a case, appropriately categorize cases and identify required actions in accordance with state and federal regulations.
Produce and manage outbound documents, correspondence and reports in a manner that meets required timeframes.
Ensure adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required timeframes.
Prepare case files for State Fair Hearings, Independent Review Entities or other escalated types of cases, including documentation of the Statement of Position and case narratives. Represent SCFHP in any hearing proceedings.
Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing.
Contact members and providers to seek additional information or clarification regarding grievance and appeals cases and review and resolve issues by requesting medical records, notice of action, or any other pertinent information related to grievances and appeals from medical groups, delegated entities and/or providers.
Perform complete, accurate and consistent data entry into system software applications in accordance with policies, procedures and instruction from the Manager of Grievance and Appeals Operations.
Maintain case files by ensuring that they are documented in accordance with state and federal requirements and organized in a manner that adheres to SCFHP standards and audit requirements.
Participate in retrospective audit and review of cases and complete and correct gaps or errors in data.
Identify operational issues and trends with SCFHP, delegates and other external stakeholders. Communicate these issues internally and externally and assist in formulating appropriate remediation plans.
Assist the Manager of Grievance and Appeals Operations and peers with special projects. Work collaboratively and cross-functionally with other departments to facilitate appropriate resolutions. Work as a team to complete departmental tasks to meet deadlines and accomplish department objectives.
Attend and actively participate in Grievance and Appeals Committee meetings, operational meetings and department meetings, trainings and coaching sessions.
Perform other related duties as required or assigned.