Appeals & Grievances Coordinator I

MedImpact Healthcare Systems; San Diego (CA); On-site; USD 25,000 - 38,000; Full time

Job summary

MedImpact Healthcare Systems is seeking an Appeals and Grievances Coordinator I to manage appeals and grievances processing with accuracy and timeliness. You will use systems like MedAccess, MedResponse, FileNet and RightFax to perform data entry and analysis under supervision.

The role requires strong customer service skills, confidentiality, and ability to multitask, including weekend shifts. Prior experience in appeals/grievances is beneficial, with a non-exempt status in the United States.

Qualifications

• GED/HS Diploma and 1+ year experience or equivalent combination of education and experience.

Responsibilities

• Evaluate and process Appeals and Grievances per established work instructions and approved departmental documents.
• Perform and document outreach activities (outbound calls/faxes) to obtain information for processing Appeals and Grievances or communicate results.
• Ensure Appeals and Grievances are finalized within the required turnaround time (TAT) per laws and company policies.
• Cross-train across the appeal and grievance task divisions.
• Participate in rotating weekend on-call schedule as needed.
• Protect confidentiality and privacy of members' health information per federal requirements and company policies.

Education

GED/HS Diploma and 1+ year experience or equivalent combination of education and experience

Tools

MS Office

Job description

Exemption Status: United States of America (Non-Exempt)

$17.92 - $22.85 - $27.78 "Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors. A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate."

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

Job Description

Summary

The Appeals and Grievances (A&G) team is responsible for managing all aspects of the appeals and grievances process, including-but not limited to-intake, processing, notification, and compliance. The Appeals and Grievances Coordinator I serves as a key member of the A&G team, processing appeal and grievance requests in accordance with established standards for accuracy, timeliness, productivity, client performance commitments, and regulatory requirements (e.g., state and federal regulations, professional accreditations). This position reports directly to the Supervisor of Appeals and Grievances Operations and is led by the Lead Coordinator (Coordinator III). The Coordinator I utilizes various business applications-such as MedAccess, MedResponse, FileNet and RightFax - to perform analysis, retrieve information, and enter data as needed to complete assigned tasks. Strong reasoning skills are essential for evaluating appeal and grievance requests for appropriateness and ensuring adherence to required processes. The ability to multitask and cross-train in both appeals and grievances processing is essential to support the weekend rotation schedule. Interact with internal and external customers as required. Work under general supervision, relying on work instructions, policies & procedures, and available company resources to perform the functions of the position efficiently and effectively.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Evaluate and process Appeals and Grievances per establish work instructions and approved departmental documents.
• Perform and document outreach activities (including outbound calls and faxes) to obtain information necessary for processing Appeals and Grievances or to communicate the results of Appeal and Grievance reviews.
• Ensure Appeals and Grievances are finalized within the required turnaround time (TAT) in accordance with applicable laws and company policies.
• Must be able to cross-train across the appeal and grievance task divisions.
• Participating in the rotating weekend on-call schedule as needed.
• Protect and maintain confidentiality and privacy of all members' personal and health information in accordance with federal requirements and company policies.
• Must comply with company and department policies, procedures, rules and regulations.
• Must possess the ability to adapt to departmental changes as required for the needs of the business. Must be flexible with shift changes.

Supervisory Responsibilities

No supervisory responsibilities

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written). One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

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

GED/HS Diploma and 1+ year experience or equivalent combination of education and experience

Computer Skills

To perform this job successfully, an individual should have knowledge of MS Office Suite. Proficiency of knowledge of Micros