Remote Grievance System Specialist - Temporary

Advanced Health Coordinated Care Organization; Oregon (WI); On-site; USD 64,471,680 - 83,840,736; Full time

Job summary

Advanced Health Coordinated Care Organization is seeking a TEMPORARY Grievance System Specialist to support our member grievance and appeal processes. This remote, non-exempt role requires careful documentation, timely communication with members and providers, and adherence to state and federal guidelines.

The ideal candidate has a high school diploma with healthcare administration experience preferred, strong analytical and communication skills, and the ability to work independently in a

Qualifications

• Minimum High School Diploma or GED; associate or bachelor’s degree in business or healthcare administration preferred; experience in lieu of degree will be considered
• Minimum one to two years’ experience in managed care or other healthcare setting
• One to two years’ experience investigative, reporting, or information analysis strongly preferred
• THW Certification preferred, or willing to obtain - Must reside in Oregon
• Bilingual preferred, qualified, certified, or willing to obtain

Responsibilities

• Create and maintain positive relationships between organization, Advanced Health members, delegates, and providers
• Coordinate denials, grievances, appeals, and hearings throughout the lifecycle
• Conduct investigations using internal and external systems; collect information from members, providers, and delegates
• Verify eligibility, authorizations, claims processing, plan coverage information
• Maintain knowledge of applicable Oregon rules and guidelines
• Ensure notices of adverse benefit determinations are handled properly
• Document and maintain accurate grievance system records
• Maintain timely correspondence with all parties per regulations and policies
• Ensure grievances and appeals are resolved within regulatory timelines
• Prepare files for administrative hearings and audits
• Monitor for related issues such as second opinions, billing, discrimination or retaliation
• Educate members and providers about grievance rights and processes
• Assist members with completing forms and translation services as needed
• Provide regular reports on grievance activity and trends
• Participate in quality and process improvement activities
• Handle confidential information securely
• Other duties as assigned
• Openly share information and collaborate with team members

Skills

Attention to detail

Effective communication

Analytical thinking

Team collaboration

Time management

Bilingual

Education

High School Diploma

Healthcare administration degree preferred

Tools

Microsoft Office

Windows OS

Job description

Advanced Health Coordinated Care Organization is seeking a TEMPORARY Grievance System Specialist to support our member grievance and appeal processes. This remote, non-exempt role requires careful documentation, timely communication with members and providers, and adherence to state and federal guidelines.

The ideal candidate has a high school diploma with healthcare administration experience preferred, strong analytical and communication skills, and the ability to work independently in a