Grievance & Appeals Coordinator I

Community Health Plan of Washington•Seattle, WA

3d•Onsite

About The Position

The Grievance & Appeals Coordinator is responsible for the management, coordination and resolution of member and provider complaints, grievances, and appeals, ensuring compliance with state and federal regulatory requirements, contractual arrangements, NCQA standards and Plan policies.

Requirements

Possess a High School Diploma, or any combination of academic education, professional training, or work experience.
Have a minimum of (1) year operational experience in a managed health care environment
Have experience with Medicaid and Medicare programs.
Will have prior experience working with grievance/appeal resolution.
Are comfortable making presentations to groups and responding to question
Proficiency in Microsoft Word, Excel, and
Ability to meet deadlines as established by state and federal regulations, NCQA, contractual obligations and Plan policies
Strong analytical skills
Strong written and verbal communication skills; able to communicate with and collaborate effectively with physicians and allied health care providers.
Strong attention to detail
Ability to maintain a professional demeanor and confidentiality at all
Strong organizational, time management, and project management skills
Ability to handle multiple priorities
Collaborate with others in a respectful manner
Complete and successfully pass a criminal background check
Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency

Nice To Haves

Knowledge of medical terminology and coursework (strongly preferred).

Responsibilities

Provides basic grievance and appeals guidance and support to a limited number of
Resolve grievances and appeals, which includes: Sending the appropriate acknowledgement of the grievance/appeal; Providing education about the grievance/appeal process and the right to appeal to state or federal agencies (if applicable); Gathering all pertinent and relevant information regarding the grievance/appeal, determining the appropriate resolution of the grievance/appeal per standard policies and procedures; and Notifying the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.
Conducts non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal.
Thoroughly documents all action taken on behalf to resolve the grievance/appeal.
Ensures that all grievances/appeals are processed in adherence to state and federal regulations, contractual obligations, NCQA guidelines and Plan policy.
Prepares clear, objective, accurate and comprehensive case
Maintains accurate and timely documentation, including complete files of all grievances/appeals.