Member Complaints & Grievances Intake Coordinator, I

UPMC•Pittsburgh, PA

2d•Remote

About The Position

UPMC Health Plan has an exciting opportunity for a Member Complaints & Grievances Coordinator, I position in the Member CGA department. This is a full time position working Monday through Friday daylight hours and is a remote position. The C&G Coordinator I will manage accurate and timely case entry and classification in the Complaints and Grievances (C&G) information system. Accurately maintain C&G data files.

Requirements

High school graduate or equivalent required.
Two years of work experience in claims or customer service required.
Proficiency in typing required.
Excellent communication, organizational, and customer services skills.
Detail-oriented, knowledge with Microsoft Word and Excel.
Demonstrate a positive and professional attitude.
Problem solving and decision-making skills with a solid understanding of managed care principles.
Knowledge of all product lines and ability to follow decision tools to assist with appropriate classification of all product lines and regulatory rules.
Critical thinking skills are crucial, as every case and investigation needs may vary, depending on member statements and other investigation findings.
Ability to remain flexible and responsive as requirements and case-handling expectations change regularly.

Nice To Haves

five years of managed care or health insurance experience preferred.
General understanding for the different appeal rights associated with each line of business.

Responsibilities

Conduct case intake process for statements received through verbal and written requests and set up new cases in the C&G information system.
Classify member complaints/appeals based on line of business/product according to department and regulatory standards and appeal rights.
Completing appropriate investigation which may include investigation of previous appeals, claims, authorizations, and inbound calls.
A prompt response to all follow-up needs on every case is vital, for compliance needs as well as member satisfaction.
Ensure member and provider concerns are thoroughly and accurately addressed according to regulatory guidelines.
Organize all tasks within regulatory requirements/deadlines.
Access and navigate multiple health plan systems to support accurate case classification, including MHK, MC400, Skygen, Health Planet, FileNet, CCD, PA Hub, and HP Capture and Route. Additionally, utilize PA Keystone State resources to properly review and process member Fair Hearing documentation.
Accurately and promptly assess, enter, and maintain documents in files and/or databases to assure that information is organized and readily available.
Respond and address incoming messages via department FileNet folders, emails, fax system, or phone CUTs in an accurate and prompt manner.
Triage and respond to inquiries as appropriate or note and distribute as needed.
Retrieve, copy, collate, and file various documents associated with the complaints and grievances processes.
Identify and escalate priority and expedited issues to all product leadership within a timely manner.
Support the team's efforts to improve performance against measured service operation goals.
Complete data entry into various information systems to support C&G processes.
Entering coverage determinations into systems of record.
The ability to quickly adapt to system outages and issues by identifying effective workarounds and maintaining operational continuity.
Support implementation of appeals tracking system.