Grievance and Appeals Coordinator

2 weeks ago

Orange, United States Cross Country Workforce Solutions Group Full time
Job DescriptionJob Description

Position Summary

Program Assistant

Under general supervision, the Program Assistant will assist with specialized services relevant to the Grievance and Appeals Resolution Services (GARS) department. The incumbent will work independently, exercising discretion and judgment and may assist in coordinating a function for the program assigned. The incumbent will be responsible for monitoring the GARS member and provider mailbox, fax, mail and processing appeals and grievances for assignment to key staff within the required timeframe.


Position Information:

* Department: Grievance & Appeals
* Work Arrangement: Full Office

 

Duties & Responsibilities:

Program Support
* Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
* Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
* Serves as the point of contact within or outside the company for inquiries related to grievances and appeals.
* Monitors incoming complaints via the Customer Service system routing, interdepartmental referral, mail, telephone, fax or via email from the website for members and providers.
* Monitors inquiry requests from the Department of Managed Health Care (DMHC), Medicare Complaint Tracking Module (CTM) from the Centers for Medicare Medicaid Services (CMS), Medicare Quality Improvement Organization (QIO) and the State Hearing Office from Department of Social Services (DSS).
* Responds to DMHC requests for information in a timely manner.
* Sets up complaint case files, enters cases in the GARS system with accurate classification and category types and assigns them to appropriate staff.

Administrative Support
* Works with internal and external departments and providers in gathering supporting information relevant to the case.
* Generates acknowledgment letters for all lines of business per department and regulatory standards.
* Assists in the development of departmental forms and intake processes.
* Coordinates administrative support for state hearings, serves as a contact with DSS for incoming cases, enters cases in the GARS system, creates electronic files and routes the scanned documents to designated staff and fax required state hearing documentation to the local hearing office as necessary.


Other
* Completes other projects and duties as assigned.

 

Requirements

Minimum Qualifications:

* • High School diploma or equivalent required.
• 1 year of experience in appeal and grievance guidelines or Medi-Cal/Medicaid or Medicare programs required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
 

Preferred Qualifications:

* • Bilingual in English and in one of the following (Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese).
 

Knowledge & Abilities:

* Develop rapport and establish and maintain effective working relationships with leadership and staff and external contacts at all levels and with diverse backgrounds.
* Work independently and exercise sound judgment.
* Communicate clearly and concisely, both orally and in writing.
* Work a flexible schedule; available to participate in evening and weekend events.
* Organize, be analytical, problem-solve and possess project management skills.
* Work in a fast-paced environment and in an efficient manner.
* Manage multiple projects and identify opportunities for internal and external collaboration.
* Motivate and lead multi-program teams and external committees/coalitions.
* Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

Company DescriptionCross Country Workforce Solutions Group (CCWSG) is a human resource, consulting and talent acquisition firm, specializing in PACE Programs, FQHCs/CHCs, and State Healthcare plans throughout the US. Our national operations center is located in Southern California.
CCWSG provides clinical and non-clinical staffing support to PACE centers across the country; we are the nation’s exclusive provider of non-medical, in-home caregivers for the elderly enrolled in PACE programs. Currently, we have over 3,000 caregivers supporting patients in their homes through PACE.
We are a part of the Cross Country Healthcare family, a market-leading workforce solutions, tech-enabled talent platform, and staffing, recruitment, and advisory firm with almost 40 years of industry experience and insight. We are a full-service partner, combining market expertise and services, including contingent staffing, consulting, human capital, management solutions, recruitment process outsourcing, vendor management, and direct hiring.Company DescriptionCross Country Workforce Solutions Group (CCWSG) is a human resource, consulting and talent acquisition firm, specializing in PACE Programs, FQHCs/CHCs, and State Healthcare plans throughout the US. Our national operations center is located in Southern California.\r
CCWSG provides clinical and non-clinical staffing support to PACE centers across the country; we are the nation’s exclusive provider of non-medical, in-home caregivers for the elderly enrolled in PACE programs. Currently, we have over 3,000 caregivers supporting patients in their homes through PACE.\r
We are a part of the Cross Country Healthcare family, a market-leading workforce solutions, tech-enabled talent platform, and staffing, recruitment, and advisory firm with almost 40 years of industry experience and insight. We are a full-service partner, combining market expertise and services, including contingent staffing, consulting, human capital, management solutions, recruitment process outsourcing, vendor management, and direct hiring.

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