YOUR WORK

In this role, you will:

• Answer telephone inquiries regarding member appeals.
• Respond to appeals and grievances and member reconsiderations.
• Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process.
• Interpret and explain health plan benefits, policies, procedures and functions to members and providers.
• Prepare files for clinician review.
• Provide guidance to and act as authoritative source for others within same skill set.
• Administer ongoing grievance tracking, trending, and reporting for assigned grievances.
• Review incoming appeals and grievances and determine which area to assign case to or reroute if the issue does not meet appeal or grievance criteria.
• Work in a collaborative manner with your team to meet compliance timeframes.
• Manage your time independently to ensure that all job duties are completed in a timely manner.

YOUR KNOWLEDGE AND EXPERIENCE

• Requires a high school diploma or GED
• Requires at least 4 years combined operations experience such as I&B, Claims, Customer Services, Regulatory Affairs; of which at least 1 year of direct experience is in Appeals/Grievances, or similar combination
• Requires knowledge of Microsoft Systems such as Power Point, Excel, and Word
• Commercial appeals and grievances knowledge or experience preferred
• Note: You may be placed in a specialty client, or other unit, such as CalPERs.

YOUR ROLE

The Appeals and Grievances team receives, documents, investigates, refers, and coordinates grievances, appeals and complaints for our Commercial line of business. The Appeals and Grievances, Advanced Coordinator will report to the Appeals and Grievances Supervisor. In this role you will be responsible for taking incoming telephone calls, reviewing, researching, and responding to incoming appeals and grievances within established compliance timeframes.

In this role, you will:

• Answer telephone inquiries regarding member appeals.
• Respond to appeals and grievances and member reconsiderations.
• Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process.
• Interpret and explain health plan benefits, policies, procedures and functions to members and providers.
• Prepare files for clinician review.
• Provide guidance to and act as authoritative source for others within same skill set.
• Administer ongoing grievance tracking, trending, and reporting for assigned grievances.
• Review incoming appeals and grievances and determine which area to assign case to or reroute if the issue does not meet appeal or grievance criteria.
• Work in a collaborative manner with your team to meet compliance timeframes.
• Manage your time independently to ensure that all job duties are completed in a timely manner