Appeals & Grievance Coordinator

Location: Remote - FL, Florida US

Notice

This position is no longer open.

Job Number: 4253

Workplace Type: Fully Remote

Position Title: Appeals & Grievance Coordinator

External Description:

External Description:

Alignment Healthcare is seeking a customer service and detail oriented appeals & grievance coordinator to be responsible for the day to day functions of the tracking and trending of all grievances, appeals, and complaints received within the member services department. As an appeals & grievance coordinator, you will act as the primary investigator and contact person for member and provider grievances and appeals.

Essential Duties and Responsibilities
(May include but are not limited to:)

  • Acknowledge receipt of all grievance/appeals, and CTM (Complaint Tracking Module).
  • Gather 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.
  • Document thoroughly 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 plan staff, providers, members, and regulators.
  • Other duties as assigned.

Minimum Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Education and/or Experience:  High school diploma or general education degree (GED)
  • Certificates, Licenses, Registrations:  None required.
  • Other Qualifications: 
    • Knowledge of Medi-Cal or Medicare Managed Care Plans.
    • Minimum 3 years' customer service experience.
    • Minimum 2 years' Appeals & Grievance experience.
    • Bi-lingual English / Spanish (preferred.)

Skills and Abilities

  • Language Skills:  Able to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals.  Able to write routine reports and correspondence.  Ability to speak effectively before groups of customers or employees of the organization.
  • Mathematical Skills:  Able to add and subtract two digit numbers and to multiply and divide with 10’s and 100’s.  Able to perform these operations using units of American money and weight measurement, volume, and distance.
  • Reasoning Skills:  Able to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.  Able to deal with problems involving a few concrete variables in standardized situations.
  • Computer Skills:  Strong computer skills.
  • Other skills and abilities:
    • Excellent written and verbal communication skills.
    • Strong telephone techniques.
    • Accurate data entry.
    • Strong organizational skills.
    • Type minimum 40 words per minute (WPM)
    • Experience with 10-key typing by touch. 

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear.
  • The employee is frequently required to walk; stand; reach with hands and arms.
  • The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl.
  • The employee must occasionally lift and/or move up to 20 pounds.
  • Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Working Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

City: Remote - FL

State: Florida

Location City: Remote - FL

Location State: Florida

Community / Marketing Title: Appeals & Grievance Coordinator

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].