Grievances and Appeals Coordinator (Temporary)

Santa Clara County Health Plan; California, San Jose (MO, CA); On-site; USD 64,000 - 97,000; Full time

Job summary

An established industry player is seeking a Grievances and Appeals Coordinator for a temporary position. This role is pivotal in managing the grievance and appeals process, ensuring compliance with regulatory standards while providing exceptional service to members and providers. The ideal candidate will possess strong communication skills, a detail-oriented mindset, and the ability to handle complex issues effectively. Join a team that values collaboration and strives to make a positive impact in the healthcare sector. If you are passionate about helping others and thrive in a dynamic environment, this opportunity is perfect for you.

Qualifications

• Minimum two years of experience in managed care or healthcare handling escalated issues.
• Knowledge of health plan operations and benefits is essential.

Responsibilities

• Manage the grievance and appeals process for members and providers.
• Ensure compliance with state and federal regulations in case handling.

Skills

Customer Service

Health Plan Benefits Knowledge

Detail-oriented

Communication Skills

Research Skills

Bilingual Skills (Spanish, Vietnamese, Chinese, Tagalog)

Education

High School Diploma or GED

Associate's Degree or Equivalent Experience

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Job description

Grievances and Appeals Coordinator (Temporary)

Salary Range: $64,342 - $96,513
The expected pay range is based on factors such as experience, education, and market conditions. The range is subject to change.

Temporary position

FLSA Status: Non-Exempt

Department: Grievance and Appeals

Reports To: Supervisor, Grievance and Appeals

GENERAL DESCRIPTION OF POSITION

The Grievance and Appeals Coordinator manages the entire process of receiving, researching, and resolving grievances and appeals from members and providers across all lines of business, including escalated cases, in compliance with regulatory requirements and SCFHP policies.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Act as a backup to the Intake Specialist during high volume periods or staffing shortages, ensuring proper intake and case prioritization.
2. Ensure all cases are accurately documented with necessary details, especially for expedited cases, and maintain clear records.
3. Identify issues and required actions within cases, categorize appropriately, and comply with regulations.
4. Manage outbound communications and reports within specified timeframes.
5. Adhere to regulatory timeframes for case handling, including acknowledgment, resolution, and communication.
6. Prepare case files for hearings or escalations, including documentation and representation if needed.
7. Build professional relationships with stakeholders and communicate effectively with members and providers.
8. Gather additional information from members and providers to resolve cases effectively.
9. Accurately enter data into systems following policies and procedures.
10. Maintain organized case files in compliance with audit standards.
11. Participate in audits, review cases, and address data gaps.
12. Identify operational issues and trends, and assist in remediation efforts.
13. Support special projects and collaborate with other departments.
14. Attend meetings, trainings, and coaching sessions regularly.
15. Perform other duties as assigned.

REQUIREMENTS

The following are required or desired qualifications:

• High School diploma or GED (R)
• Associate's degree or equivalent experience (D)
• At least two years of experience in customer or health services handling complex issues (R)
• Knowledge of health plan benefits and operations (R)
• Experience with commercial, Medi-Cal, and Medicare programs, especially with underserved populations (R)
• Availability to work weekends and holidays as needed (R)
• Bi-lingual skills in Spanish, Vietnamese, Chinese, or Tagalog (D)
• Detail-oriented with research skills (R)
• Adaptability to changing situations (R)
• Ability to meet accuracy and timeline standards (R)
• Proficiency in Outlook, Word, Excel (R)
• High accuracy in keyboard use (R)
• Excellent communication skills and ability to de-escalate situations (R)
• Ability to work under pressure and prioritize tasks (R)
• Good judgment and decision-making skills (R)
• Maintain confidentiality (R)
• Compliance with policies and safety standards (R)

WORKING CONDITIONS

Primarily office environment with frequent interactions and interruptions.

PHYSICAL REQUIREMENTS

1. Mobility: Bending, reaching, sitting, standing (R)
2. Lifting: Up to 5 pounds regularly (R)
3. Visual: Ability to read printed and digital info (R)
4. Dexterity: Use of hands and fingers for keyboard and writing (R)
5. Hearing/Talking: Communicate effectively in person and by phone (R)
6. Reasoning: Work effectively under pressure, make decisions, and pay attention to details (R)

ENVIRONMENTAL CONDITIONS

Standard office and call center settings with moderate noise levels.

EOE