Description:
Impresiv Health is seeking a Grievance and Appeals Coordinator to support the administrative functions and daily activities associated with processing member and provider grievances and appeals for a health plan organization.
Under the general direction of Grievance and Appeals leadership, this position is responsible for coordinating, documenting, tracking, and supporting grievance and appeal cases while ensuring compliance with established regulatory requirements, departmental procedures, and applicable health plan guidelines.
The Grievance and Appeals Coordinator will use independent judgment to identify potential issues, escalate trends or deficiencies when appropriate, and support the timely resolution of member and provider cases.
This position also supports organizational quality initiatives, including programs and standards related to HEDIS, CAHPS, and NCQA Accreditation.
What You Will Do:
- Maintain a working knowledge of regulatory requirements and guidelines related to grievances and appeals, including CMS, DHCS, and DMHC requirements.
- Understand member and provider rights regarding access to the grievance and appeals resolution process.
- Support compliance with grievance and appeals processes in accordance with applicable health plan regulatory agencies.
- Coordinate, document, and track member and provider grievances and appeals.
- Provide administrative support to ensure grievance and appeal cases are processed according to regulatory requirements and internal departmental protocols.
- Generate written correspondence to members, providers, and regulatory entities using appropriate grammar, punctuation, and professional communication standards.
- Ensure required grievance and appeal correspondence is distributed within established regulatory timelines.
- Assist internal teams with filing, tracking, documenting, and closing member and provider grievances.
- Review and intake new cases when assigned and route cases for medical urgency review and appropriate investigation.
- Identify immediate case needs and communicate them to the appropriate team member.
- Support the determination of the appropriate investigative approach, documentation requirements, and provider involvement based on case circumstances and established procedures.
- Serve as a liaison between internal departments to obtain necessary information and support the timely resolution of grievances and appeals.
- Monitor open and pending grievance and appeal cases and communicate unresolved issues and expected resolution activities to department leadership.
- Prepare grievance and appeals reports and summaries as requested.
- Assist management with reviewing grievance and appeal information to identify opportunities for improvements to policies, procedures, and operational processes.
- Collaborate with team members to support departmental protocols, performance goals, and organizational objectives.
- Incorporate LEAN principles into daily work and process improvement activities.
- Communicate directly with health plan members when necessary to clarify information required to appropriately process a grievance or appeal.
- Respond to member questions regarding the status or processing of their grievance or appeal.
- Maintain a strong focus on regulatory compliance, accuracy, timeliness, and customer service.
You Will Be Successful If:
- You have a strong understanding of healthcare customer service and managed care operations.
- You can effectively manage multiple cases, tasks, and deadlines in a highly regulated environment.
- You demonstrate strong attention to detail and consistently maintain accurate case documentation.
- You communicate professionally and effectively with members, providers, internal departments, and regulatory entities.
- You can prioritize workload to ensure regulatory and departmental deadlines are consistently met.
- You can quickly learn and follow established policies, procedures, workflows, and regulatory standards.
- You exercise sound judgment when identifying issues that require escalation.
- You are comfortable communicating with members by telephone to gather information, clarify concerns, and answer case-related questions.
- You demonstrate sensitivity and professionalism when working with individuals from diverse and multicultural communities.
- You work effectively in a collaborative, team-oriented environment.
- You develop professional working relationships based on respect, cooperation, accountability, and effective communication.
What You Will Bring:
- High School Diploma or GED
- Bilingual English/Spanish verbal and written communication skills.
- 3+ years of administrative experience in an office environment.
- Experience using Microsoft Office applications.
- Experience working in a managed care Member Services or Customer Service environment.
- Previous experience documenting and resolving member and provider grievances and appeals.
- Strong written and verbal communication skills.
- Strong interpersonal and administrative skills.
- Strong organizational and time-management skills.
- Ability to type at least 45 words per minute.
- Proficiency with Microsoft Word and Excel.
- Data entry experience.
- Strong telephone communication and customer service skills.
- Ability to handle multiple priorities simultaneously.
- Strong attention to detail and the ability to prioritize work according to deadlines.
- Ability to learn and consistently follow established standards and procedures.
- Ability to work independently while contributing effectively within a team environment.
Preferred Experience:
- Prior Medi-Cal experience.
- Prior Medicare experience.
- Bachelor s degree from an accredited institution.
About Impresiv Health:
Impresiv Health is a healthcare consulting partner specializing in clinical & operations management, enterprise project management, professional services, and software consulting services. We help our clients increase operational efficiency by delivering innovative solutions to solve their most complex business challenges.
Our approach is and has always been simple. First, think and act like the customers who need us, and most importantly, deliver what larger organizations cannot do: provide tangible results that add immediate value, at a rate that cannot be beaten. Your success matters, and we know it.
That s Impresiv!