Grievance & Appeals Coordinator I

Health Plan of San Mateo; Golden Horseshoe; Remote; CAD 60,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated professional to join their team in managing grievances and appeals processes. This role involves resolving member complaints, maintaining case files, and ensuring compliance with regulatory requirements. The ideal candidate will possess strong communication skills and a background in customer service, particularly within managed care. This position offers a competitive hourly wage and an excellent benefits package, including medical, dental, and retirement contributions. If you are passionate about making a difference in healthcare, this could be the opportunity for you.

Benefits

Medical, Dental, and Vision Coverage

Life, AD&D, and LTD Insurance

Retirement Plan Contribution

Paid Holidays

Paid Sick Days

Paid Vacation

Employee Wellness Program

Qualifications

• 2 years experience in managed care environment preferred.
• Associate's degree in health, business, or social sciences preferred.

Responsibilities

• Resolve member complaints ensuring compliance with policies.
• Communicate effectively with members and prepare resolution letters.

Skills

Customer Service

Effective Communication

Problem Solving

Team Collaboration

Education

Associate's Degree in Health

Experience with Medi-Cal or Medicare

Tools

Microsoft Office Suite

Job description

Health Plan of San Mateo, 701 Gateway Blvd., South San Francisco, California, United States of America ● Virtual Req #144

Thursday, May 8, 2025

Implement HPSM’s Grievance and Appeals processes by resolving complaints filed by HPSM members and their representatives as well as provide back-up support to Member Services and CareAdvantage units.

Position overview

• Research and resolve member complaints for all lines of business ensuring compliance with HPSM’s Grievance and Appeals policies and procedures.
• Maintain grievance and appeals case files in HPSM’s database.
• Effectively communicate with members and providers verbally and in writing.
• Prepare summaries and write resolution letters for members, which include summarizing member complaints and steps taken to resolve complaints in clear and grammatically correct language.
• Attend and present cases at bi-weekly Staff Grievance and Appeals Committee.
• Prepare files for appeals to regulatory agencies.
• Maintain current on all regulatory requirements as they apply to grievance and appeal processes.
• May, as needed, provide necessary coverage in the call centers for Member Services and CareAdvantage.

Requirements

These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply.

Education and experience

• Associate’s degree in health, business, social sciences, or humanities, preferred.
• Two (2) years of experience working with Medi-Cal or Medicare in a managed care environment preferred. Work performing grievance and appeals processing preferred.
• Work in a call center, claims department, and/or other customer service position required.

Knowledge of:

• Knowledge goes here
• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
• Medicare, Medi-Cal, Managed Care and medical terminology preferred.

Ability to:

• Work cooperatively with others.
• Work as part of a team and support team decisions.
• Communicate effectively, both verbally and in writing.
• Adapt to changes in requirements/priorities for daily and specialized tasks.
• Communicate effectively and professionally, both verbally and in writing.
• Summarize information clearly, thoroughly, and quickly in writing.
• Deal with difficult people and situations while providing quality customer service.
• Use sound judgment, identify next steps to be taken and develop appropriate solutions.
• Collaborate with multiple parties to solve problems; solve problems independently.

Salary and benefits

The starting salary range is $28.36 - $35.87 per hour, depending on the candidate’s work experience.

Excellent benefits package includes:

• HPSM-paid premiums for employee’s medical, dental and vision coverage (employee pays 10% of each dependent’s premiums)
• Fully paid life, AD&D and LTD insurance
• Retirement plan (HPSM contributes equivalent of 10% of annual compensation)
• 12 paid holidays a year, 12 paid sick days a year and paid vacation starting at 16 days a year
• Employee wellness program

It is HPSM's policy to provide equal employment opportunities for all applicants and employees. HPSM does not unlawfully discriminate based on race, religion, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, sexual orientation, veteran status, registered domestic partner status, genetic information, gender, gender identity, gender expression, or any other characteristic protected by applicable federal, state, or local law. HPSM also prohibits discrimination based on the perception that an applicant or employee has any of those characteristics or is associated with a person who has or is perceived to have any of those characteristics.

• Health Plan of San Mateo, 701 Gateway Blvd., South San Francisco, California, United States of America