Appeals and Grievance Coordinator- Bakersfield 1.1

Description

Employment Details:

Location: Bakersfield, CA. (Onsite)

Classification: Full-Time

This position is non-exempt and will be paid on an hourly basis.

Schedule: 

Monday- Universal Healthcare MSO's standard operating hours are Monday through Friday, from 8:00 a.m. to 5:00 p.m. Pacific Time. Unless otherwise specified, all employees are expected to work their assigned schedules and remain available during these operational hours. 

Benefits:

· Medical

· Dental

· Vision

· Paid Time Off (PTO)

· Floating Holiday

· Simple IRA Plan with a 3% Employer Contribution

· Employer Paid Life Insurance

· Employee Assistance Program

Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $26.00 and $32.49. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

Position Summary:

The Appeals and Grievances (A&G) Coordinator is responsible for supporting the end-to-end A&G process, including the intake, tracking, and resolution of member and provider complaints and appeals. This position handles low complexity cases and performs administrative tasks such as organizing case documentation, monitoring deadlines, and ensuring timely follow-up. The

A&G Coordinator collaborates with internal departments to resolve issues related to member eligibility, benefits, claims, utilization management, and pharmacy decisions. This role also involves training sessions and cross-functional work groups aimed at improving operational efficiency and service quality.

Job Duties and Responsibilities:

• Supporting and participating in process improvements, system enhancement testing, new process implementations and documenting adjustments as requested.

• Maintaining appeal and grievance data through tracking mechanisms and processing case requests as necessary to support regulatory, internal or external requirements including

audits.

• Performs administrative duties to track, organize, monitor and follow-up on case work with duties including, but not limited to: Receiving, opening, tracking and routing Appeal and Grievance mail, faxes, email, voicemail and case correspondence.

• Reviewing Appeal and Grievance correspondence and case requests.

• Create new cases in the health plan appeals and grievances tracking application along with scanned documentation where applicable.

• Intaking, entering, tracking and updating State Fair Hearing (SFH) notices and informing

Grievance staff assigned to SFH’s of any updates, along with providing administrative support during scheduled SFH’s.

• Track appeal requests to the Livanta BFCC-QIO, an independent reviewer, to extend Health plan member covered services.

• Providing outreach to members and provider inquiries and requests through a variety of methods including phone, fax, web, and written correspondence.

• Engages in departmental and cross-departmental training, workgroups, and operational improvement activities, with duties that include but are not limited to: Attending Grievance and Appeals Committee meetings and preparing and presenting agenda items

for committee as approved or assigned by Grievance/Appeal Leadership.

• Attending monthly Department meetings and preparing and presenting agenda items for the Department as assigned by Grievance/Appeal Leadership.

• Participating in cross-departmental work groups, grievance system trainings and initiative meetings as assigned.

• Sharing information from workgroups and initiatives with the Grievance/Appeal Team during weekly Team meetings.

• Performs other duties as assigned.

Requirements

Qualifications:

• Associate’s degree in health, social services or a related healthcare or equivalent work experience in related healthcare preferred.

• One year of experience in a managed health care setting, health plan, or provider office.

• Interacting with members, patients, and/or providers and experience with receiving complaints, preferably related to healthcare administration.

Key Skills and Knowledge:

• Bilingual (English/Spanish) preferred.

• Working knowledge of customer service principles and practices.

• Working knowledge of the principles and practices of managed healthcare, healthcare coverage and benefit structures, principles of coordination of benefits and medical billing.

• Working knowledge of and proficiency in Microsoft Word, Outlook, Acrobat Adobe and Excel.

• Possess a practical understanding of research methods, analysis techniques, and reporting processes.

• Capability to conduct telephone interviews in a confidential and sensitive manner effectively.

• Working knowledge of conflict resolution techniques.

• Ability to address sensitive or challenging issues with tact and diplomacy.

• Proficiency in listening, de-escalation techniques, and critical thinking skills.

Physical Requirements & Working Conditions

Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions of this position.

This position is primarily performed in a professional office environment and requires the ability to:

• Frequently remain seated and occasionally stand and walk throughout the workday while performing assigned duties.
• Occasionally bend, twist, reach forward and overhead, squat, kneel, or crawl as necessary to perform assigned duties.
• Occasionally lift materials weighing up to 15 pounds from floor to waist level and up to 10 pounds from waist level and above.
• Occasionally carry, push, pull, and transport work-related materials or equipment.
• Occasionally perform tasks requiring wrist position deviation, pinching, and fine motor coordination.
• Frequently use a computer, keyboard, mouse, telephone, and other equipment requiring repetitive hand and wrist movements.
• Frequently communicate effectively through talking and hearing to receive, understand, and exchange information.
• Possess sufficient near vision (20/20), far vision (20/40), color discrimination, depth perception, and hearing ability to perform assigned duties.
• Work in an environment where exposure to bloodborne pathogens, chemicals, airborne communicable diseases, extreme temperatures, radiation, uneven surfaces or elevations, extreme noise levels, and dust or particulate matter is not anticipated.