Description

Hourly Pay Range: $24.81 - $34.74

This position will provide for the facilitation of member grievances and appeals (G&A) and member billing issue cases as assigned by the MS Grievance and Appeals Supervisor. This position must be committed to service recovery and perform at a high level regarding research, resolution, and strong verbal and especially written communication skill set meeting all regulatory and contractual requirements. The Grievance and Appeals (G&A) Coordinator must demonstrate a thorough understanding of CenCal Health’s benefits and any applicable coordination of benefits. This position must have a thorough knowledge and understanding of applicable copayments and coinsurance with other healthcare coverage, pharmacy formulary, provider network, and appropriate interactions with local government and CBO agencies.

Duties and Responsibilities

• Maintain assigned G&A and member billing caseload along with appropriate overview of G&A documentation of member grievance and appeal descriptions from Call Center team and contact with members should description not provide needed information for the appropriate categorization of G&A cases for Health Services review and approval

• Initiate investigation, research, prepare clinical G&A packets for Health Services QI nurse and Medical Director, and resolution of G&A cases that do not require clinical professional review and outcome for Grievance Manager’s review and approval

• Provide final letter to members within mandated resolution time frames and complete G&A packet for Grievance & QI Supervisor’s review and approval

• Assure compliance with the Health Plan’s G&A Policies and Procedures which are aligned with government regulations and laws

• Provide high-level customer service through the appropriate and accurate in-depth research and resolution of member grievances, appeals, and billing issues including those complex cases and retro cases from state referrals that require in-depth knowledge of provider claims submission and benefit understanding within established & mandated service levels. The G&A Coordinator is research fluent with reference databases and has the ability to handle a high volume of cases within the specified periods

• Provide feedback to Member Services Call Center Managers regarding appropriate and complete documentation for the Member Grievance and Appeal System

• Establish and maintain effective and cooperative working relations with internal health plan staff, and outside collaborative agencies such as DSS, Public Health Department, Tri-Counties Regional Centers, California Children’s Services, Public Authority, Alcohol Drug and Mental Health for SB County and Mental Health Services for SLO County, Social Security Administration and network providers

• Provide support and investigative assistance regarding State Fair Hearings to the Director of Member Services and Director of Legal Affairs

• Log, research, and successfully coordinate complicated Continuity and Coordination of Care Cases for members

• Other duties as assigned

Qualifications

Knowledge/Skills/Abilities

Required:

• Demonstrate a thorough understanding of CenCal’s various healthcare program benefits, Share of Cost, eligibility, coordination with other healthcare coverage, coordination with the local government and CBO agencies, PMB, Pharmacy formularies specific to individual Program benefits, and understanding of the Plan Provider Network requirements necessary for the resolution of member grievance and appeals and member billing issues. This position must have extensive knowledge of hospital, physician, and provider office protocols, medical record requests, research, and investigative skills necessary for the appropriate clinical review of appeal and quality of care cases

• Must have the ability to multi-task

• Demonstrate good judgment in making decisions within the scope of the position

• Ability to work independently with minimal supervision

• Excellent oral and written communication skills

• For those bilingual positions, one must be fluent in Spanish per testing results by the Plan consultant

• Must be able to demonstrate a complete knowledge of the Plan HIS screens noted below while meeting established service standards for resolution times, accuracy, Customer Satisfaction, and the ability to take on special projects as assigned by the Grievance & QI Manager and/or Director

Education and Experience

• Bachelor's Degree in Health Administration, Business, Social Sciences, or related field, or four (4) years experience in a managed care environment or similar field relating to member grievance, appeals, and complex member billing issues necessitating claims understanding

• Data collection and analysis experience

• Knowledge of and ability to utilize conflict resolution and problem-solving techniques.

• Knowledge of Medi-Cal or managed care setting preferred

• Knowledge of Microsoft Word, Windows, Microsoft Excel or similar spreadsheet, and Microsoft Access or similar database