Grievance & Appeals Coordinator I

Who we are

About the Role

Is responsible for the management, coordination and resolution of member and provider complaints, grievances, and appeals, ensuring compliance with state and federal regulatory requirements, contractual arrangements, NCQA standards and Plan policies.

To be successful in this role, you:

• Possess a High School Diploma, or any combination of academic education, professional training, or work experience.
• Have a minimum of (1) year operational experience in a managed health care environment
• Have experience with Medicaid and Medicare programs.
• Will have prior experience working with grievance/appeal resolution.
• Have knowledge of medical terminology and coursework (preferred).
• Are comfortable making presentations to groups and responding to questions

Essential functions and Roles and Responsibilities:

• Provides basic grievance and appeals guidance and support to a limited number of providers.
• Resolve grievances and appeals, which includes:
  • Sending the appropriate acknowledgement of the grievance/appeal; Providing education about the grievance/appeal process and the right to appeal to state or federal agencies (if applicable);
  • Gathering all pertinent and relevant information regarding the grievance/appeal, determining the appropriate resolution of the grievance/appeal per standard policies and procedures; and
  • Notifying the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue.
• Conducts non-biased, accurate, timely and comprehensive investigation of all the facts related to the grievance/appeal.
• Thoroughly documents all action taken on behalf to resolve the grievance/appeal.
• Ensures that all grievances/appeals are processed in adherence to state and federal regulations, contractual obligations, NCQA guidelines and Plan policy.
• Prepares clear, objective, accurate and comprehensive case histories.
• Maintains accurate and timely documentation, including complete files of all grievances/appeals.
• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Knowledge, Skills, and Abilities:

• Proficiency in Microsoft Word, Excel, and Outlook.
• Ability to meet deadlines as established by state and federal regulations, NCQA, contractual obligations and Plan policies.
• Excellent analytical skills.
• Excellent written and verbal communication skills; able to communicate with and collaborate effectively with physicians and allied health care providers.
• Excellent attention to detail.
• Well-developed organizational and time management skills.
• Ability to handle multiple priorities.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Non-Exempt and is) eligible for overtime. Based on market data, this position grade is 39 and has a 5% annual incentive target based on company, department, and individual performance goals.

CHPW offers the following benefits for Full and Part-time employees and their dependents: 

•  Medical, Prescription, Dental, and Vision
•  Telehealth app
•  Flexible Spending Accounts, Health Savings Accounts
•  Basic Life AD&D, Short and Long-Term Disability
•  Voluntary Life, Critical Care, and Long-Term Care Insurance
•  401(k) Retirement and generous employer match
•  Employee Assistance Program and Mental Fitness app
•  Financial Coaching, Identity Theft Protection
•  Time off including PTO accrual starting at 17 days per year.
•  40 hours Community Service volunteer time
•  10 standard holidays, 2 floating holidays
•  Compassion time off, jury duty

Sensory/Physical/Mental Requirements:

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking and possibly standing
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion
• Frequent torso/back static position; occasional stooping, bending, and twisting.

Mental:

• Frequent decision-making. Ability to gather and assess data, determine appropriate actions, apply protocols and knowledge to unique situations, problem-solve and provide consultation.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.