Grievance and Appeals Coordinator

1 month ago

San Jose, California, United States Ultimate Staffing Full time
Job Title: Grievance and Appeals Coordinator

Ultimate Staffing is seeking a highly skilled Grievance and Appeals Coordinator to join our team in San Jose, CA. This is a 6-month contract position with a remote schedule and occasional travel to our office in San Jose, CA.

Job Summary:

The Grievance and Appeals Coordinator is responsible for managing the entire process of receiving, researching, and resolving member and provider grievances and appeals cases for all lines-of-business. This includes ensuring compliance with state and federal regulatory requirements and company policies and procedures.

Key Responsibilities:
  1. Act as a backup to the Grievance and Appeals Intake Specialist during high-volume work and/or staffing shortages to ensure timely intake of new and existing cases.
  2. Ensure cases are accurate and complete, with a focus on expedited cases, and create clear documentation in applicable systems.
  3. Use judgment and department resources to identify issues and required actions within cases, categorize cases, and identify required actions in accordance with state and federal regulations.
  4. Produce and manage outbound documents, correspondence, and reports within required timeframes.
  5. Ensure adherence to state and federal regulatory timeframes for handling cases, including acknowledging cases, resolving cases, and communicating with members and providers.
  6. Prepare case files for State Fair Hearings, Independent Review Entities, or other escalated cases, including documentation of the Statement of Position and case narratives.
  7. Develop effective working relationships with internal and external stakeholders and partners, communicating effectively with members and providers orally and in writing.
  8. Contact members and providers to seek additional information or clarification regarding cases and review and resolve issues by requesting medical records, notice of action, or other pertinent information.
  9. Perform accurate and consistent data entry into system software applications in accordance with policies, procedures, and instructions from the Manager of Grievance and Appeals Operations.
  10. Maintain case files, ensuring they are documented in accordance with state and federal requirements and organized in a manner that adheres to SCFHP standards and audit requirements.
  11. Participate in retrospective audit and review of cases, completing and correcting gaps or errors in data.
  12. Identify operational issues and trends with SCFHP, delegates, and other external stakeholders, communicating these internally and externally and assisting in formulating remediation plans.
  13. Assist the Manager of Grievance and Appeals Operations and peers with special projects, working collaboratively and cross-functionally with other departments to facilitate resolutions.
  14. Attend and actively participate in Grievance and Appeals Committee meetings, operational meetings, and department meetings, trainings, and coaching sessions.
Requirements:

To be successful in this role, you will need:

  1. A high school diploma or GED.
  2. An associate's degree or equivalent experience, training, or coursework, desired.
  3. Minimum two years of experience in customer service, provider service, health service, or pharmacy in a managed care or healthcare environment handling escalated or complex issues.
  4. Knowledge of health plan benefits, processes, and operations.
  5. Prior experience with commercial, Medi-Cal, and/or Medicare programs and working with underserved populations.
  6. Ability to work weekends and company holidays as needed based on business regulatory requirements.
  7. Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills, desired.
  8. Detail-oriented with the ability to conduct research and identify steps required to resolve issues and follow through to effectuation.
  9. Ability to consistently meet grievance and appeals accuracy and timeline requirements by achieving regulatory standards.
  10. Working knowledge of and the ability to efficiently operate all applicable computer software, including Outlook, Word, and Excel.
  11. Ability to use keyboard with moderate speed and a high level of accuracy.
  12. Excellent communications skills, including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, members, providers, and outside entities.
  13. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes.
  14. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position.
  15. Ability to maintain confidentiality.
  16. Ability to comply with all SCFHP policies and procedures.
  17. Ability to perform the job safely with respect to others, property, and individual safety.

Ultimate Staffing is an equal opportunity employer and welcomes applications from all qualified candidates. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws.

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