Ultimate Staffing is looking for a Grievance and Appeals Coordinator to join a well-established healthcare company in San Jose, CA! This is a 6 month contract, remote schedule with the ability to travel to the office in San Jose, CA at times. The schedule is M-F, 8:30am to 5pm.
The Grievance and Appeals Coordinator is responsible for the beginning-to-end process of receiving, researching and resolving of new and existing member and provider grievance and appeals cases for all lines-of-business including any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and company policies and procedures as set forth for each line of business.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.
1. Act as a back-up to the Grievance and Appeals Intake Specialist during times of high volume work and/or staffing shortages to ensure appropriate intake of new and existing grievance and appeal cases, assessing the priority of each case and routing to the appropriate staff.
2. Ensure grievance and appeals cases are accurate and include the necessary elements for processing and resolving, giving special attention to those identified as "Expedite". Create clear and concise documentation in applicable system(s).
3. Use good judgment and department resources to identify all issues and required actions within a case, appropriately categorize cases and identify required actions in accordance with state and federal regulations.
4. Produce and manage outbound documents, correspondence and reports in a manner that meets required timeframes.
5. Ensure adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required timeframes.
6. Prepare case files for State Fair Hearings, Independent Review Entities or other escalated types of cases, including documentation of the Statement of Position and case narratives. Represent SCFHP in any hearing proceedings.
7. Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing.
8. Contact members and providers to seek additional information or clarification regarding grievance and appeals cases and review and resolve issues by requesting medical records, notice of action, or any other pertinent information related to grievances and appeals from medical groups, delegated entities and/or providers.
9. Perform complete, accurate and consistent data entry into system software applications in accordance with policies, procedures and instruction from the Manager of Grievance and Appeals Operations.
10. Maintain case files by ensuring that 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 and complete and correct gaps or errors in data.
12. Identify operational issues and trends with SCFHP, delegates and other external stakeholders. Communicate these issues internally and externally and assist in formulating appropriate remediation plans.
13. Assist the Manager of Grievance and Appeals Operations and peers with special projects.
Work collaboratively and cross-functionally with other departments to facilitate appropriate resolutions. Work as a team to complete departmental tasks to meet deadlines and accomplish department objectives.
14. Attend and actively participate in Grievance and Appeals Committee meetings, operational meetings and department meetings, trainings and coaching sessions.
15. Perform other related duties as required or assigned.
REQUIREMENTS:
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
1. High School diploma or GED.
2.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 health care 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 the underserved populations.
6.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.Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the Grievance and Appeals Department operations as dictated by business needs
10. Ability to consistently meet grievance and appeals accuracy and timeline requirements by achieving regulatory standards.
11. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications such as Outlook, Word and Excel.
12. Ability to use keyboard with moderate speed and a high level of accuracy.
13. Excellent communications skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, Members, Providers and outside entities over the telephone, in person or in writing. The ability to remain calm and de-escalate tense situations.
14. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes.
15. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position.
16. Ability to maintain confidentiality.
17. Ability to comply with all SCFHP policies and procedures.
18. Ability to perform the job safely with respect to others, to property and to individual safety.
All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance. To the extent our customers require a background check for certain positions, the Company faces a significant risk to its business operations and business reputation unless a review of criminal history is conducted for those specific job positions.
