Grievance & Appeals Coordinator I

Community Health Plan of Washington•Seattle, WA

3h•Onsite

About The Position

This role is responsible for the management, coordination, and resolution of member and provider complaints, grievances, and appeals. The position ensures compliance with state and federal regulatory requirements, contractual arrangements, NCQA standards, and Plan policies. The Grievance & Appeals Coordinator I provides basic grievance and appeals guidance and support to a limited number of providers. They resolve grievances and appeals by sending acknowledgements, providing education on the process and appeal rights, gathering pertinent information, determining appropriate resolutions per standard policies, and notifying parties of the resolution. The role also involves conducting non-biased investigations, thoroughly documenting all actions, ensuring adherence to regulations and guidelines, and preparing clear case histories. Accurate and timely documentation of all grievances/appeals is crucial. Other duties as assigned may be part of the role.

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.
Proficiency in Microsoft Word, Excel, and Outlook.
Ability to meet deadlines as established by state and federal regulations, NCQA, contractual obligations and Plan policies.
Excellent analytical skills.
Excellent written and verbal communication skills; able to communicate with and collaborate effectively with physicians and allied health care providers.
Excellent attention to detail.
Well-developed organizational and time management skills.
Ability to handle multiple priorities.
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 (preferred).
Are comfortable making presentations to groups and responding to questions

Responsibilities

Provides basic grievance and appeals guidance and support to a limited number of providers.
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 histories.
Maintains accurate and timely documentation, including complete files of all grievances/appeals.
Other duties as assigned.