Senior Grievance & Appeals (GAD) Coordinator

SCAN Health Insurance•Long Beach, CA

4d•$22 - $32•Remote

About The Position

The Grievances and Appeals Senior Coordinator will provide support to grievance and appeal team supervisors through support/guidance to team members, review of cases prior to closure and monitoring compliance with regulations for the team. This role is responsible for investigating member grievances and appeals by gathering supporting documentation, communicating with members or providers, and referring cases as appropriate. The Senior Coordinator will handle complex grievances and appeals, serve as a resource for team members, and track case movement to ensure compliance with timelines. They will partner with clinical staff, respond to regulatory agencies, and ensure cases are closed within regulatory timeframes. The position requires understanding SCAN’s benefit structure, utilizing department resources, identifying process improvements, and participating in a weekend on-call rotation. Maintaining member privacy and adhering to quality, compliance, and regulatory standards are essential. The role also involves supporting SCAN’s vision and goals, and potentially other duties as assigned. The company is looking for individuals who are curious about AI and its potential to transform operations.

Requirements

3+ years of grievance and appeals experience with a Health Plan, Managed Care, or Healthcare organization.
Knowledge of Medicare Part D Pharmacy benefits, rules and regulations is required.
Experience providing professional customer service.
Associate's Degree or equivalent experience.
Advanced analytical skills.
Microsoft Office (Word, Excel, PowerPoint, Access, Outlook, Teams), OneNote, and SharePoint at advanced level are required.
IKA, MHK, and/or QNXT experience is highly desired.
Advanced problem-solving skills.
Advanced communication and interpersonal skills.
Excellent writing skills and the ability to express ideas concisely and clearly orally and in writing.
Strong interpersonal skills and the ability to multitask and work independently with minimal supervision.
Strong organizational skills; Ability to multitask.
Ability to appropriately maintain confidentiality.
Strong analytical and critical thinking skills, required.
A background check is required.

Nice To Haves

IKA, MHK, and/or QNXT experience is highly desired.

Responsibilities

Investigate member grievance and appeal by gathering supporting documentation from internal departments, contracted Provider Organizations (PO) and non-contracted entities as indicated.
Communicate with members or providers to request and gather pertinent information.
Follow up as needed and document accordingly.
Refer cases to RN or management as appropriate.
Responsible for the complex grievances and appeals, providing support for escalated issues and tasks.
Serve as a resource for team members.
Track and monitor movement of assigned cases through SCAN’s functional units and systems, to ensure compliance with designated timelines.
Partner with clinical staff to complete assigned cases to meet regulatory and compliance requirements.
Respond to requests for information from all regulatory agencies within required timeframes.
Respond to and close cases within designated regulatory time requirements as identified by case types.
Generate and send appropriate communications.
Understand SCAN’s benefit structure and maintains current and additional information as it relates to Grievances and Appeals services.
Utilize department desktop procedures, workflows, job aids and training material.
Identify barriers and potential solutions to work processes and bring to the attention of the supervisor/manager.
Cover week-end on call rotation as assigned.
Maintain the member‘s right to privacy and protect SCAN operations by keeping information confidential.
Adhere to all quality, compliance and regulatory standards to achieve HCS and SCAN outcomes.
Contribute to team effort by accomplishing related results as needed.
Actively support the achievement of SCAN’s Vision and Goals.
Other duties as assigned.