Alignment Healthcare
The Appeals & Grievance Coordinator is responsible for the day-to-day functions of the tracking and trending of all grievances, appeals, and complaints received within the Member Services Department. This position will also act as the primary investigator and contact person for both member and provider grievances and appeals.
Required Skills & Experience
- Responsible for complex appeals and grievance cases; handling escalations appropriately
- Will appropriately acknowledge the receipt of all grievance/appeals, and CTM (Complaint Tracking Module).
- Responsible for the gathering of all pertinent and relevant information from the member and/or provider regarding the grievance/appeal, determining the appropriate resolution of the grievance/appeal per standard policies and procedures; and notifying the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.
- Compose written correspondence to members in accordance to plan policy and CMS Guidelines.
- Conduct non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal.
- Thoroughly document all action taken on behalf of the member or provider to resolve the grievance/appeal.
- Ensure that all grievances/appeals are processed in adherence to the Centers for Medicare and Medicaid (CMS) guidelines and plan policy.
- Prepare case files for Medical Director Review and external (including IRE) review of grievances/appeals as appropriate.
- Prepare clear, objective, accurate and comprehensive case histories for presentation and consideration at committee meetings (including Board of Directors).
- Maintain accurate and timely documentation, including complete files of all grievances/appeals. Prepare monthly and quarterly reports as requested.
- Identify training opportunities and potential system and process improvements relating to grievance/appeal data.
- Participate in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements as well as participate in periodic CMS Audit preparations and regulator meetings/interviews.
- Maintain a positive and professional relationship with CCHP staff, providers, members, and regulators.
- Other duties as assigned.
- Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10’s and 100’s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
- Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
- Computer Skills: Strong computer skills.
- Excellent communication skills.
- Excellent written skills
- Good telephone techniques.
- Excellent data entry.
- Strong organizational skills.
- Type 40+ words per minute.
- Experience with 10-key by touch.
Pay Range: $42,400.00 – $63,600.00 Annually