Grievance & Appeals Coordinator

SUMMARY

The Grievance Coordinator is responsible for timely intake, processing, researching, documenting and responding to grievances referred to Alivi by health plan partners. Responsible for entering pertinent information into the designated portal/database, communicating with contracted providers to resolve cases, communicating with contracted health plan partners, tracking case load aging, escalating issues prior to expiration of standard processing timelines, and maintaining compliance with all processing timeframes established within the department.

DUTIES & RESPONSIBILITIES

• Responsible for the handling of assigned grievances referred by contracted health plan partners, writing acknowledgements, obtaining pertinent records as needed, researching cases, resolving issues, and ensuring time frames are met for acknowledgement and resolution. Must comply with all regulatory requirements and policies of Alivi.
• Responsible for investigating and resolving all priority issues and/or concerns reported by the health plan through the grievance portal in a timely and efficient manner. These issues require immediate attention due to the nature of the concern.
• Works closely with internal departments to resolve and research health plan member grievances and to obtain additional information to provide to the health plan to adequately resolve and respond to the grievance.
• Maintains complete and accessible grievance cases via the designated portal system.
• Contacts providers and health plan partners to obtain additional information to adequately resolve and respond to assigned grievances.
• Provides timely resolution of customer complaints, concerns, and inquiries.
• Responds professionally to all customer requests related to grievances.
• Builds effective relationships and trust with customers and potential customers by listening to their needs.
• May work with appeal nurse(s) and Medical Director(s), who oversee clinical aspects of the business, to ensure that the clinical issues are appropriately evaluated.
• Demonstrates an understanding of the functions of other departments and affiliates while communicating appropriately to maintain positive working relationships. Supports department in administrative, data management and clerical duties.
• Responsible for addressing and forwarding quality of care complaints to quality management for resolution and/or assisting in investigation in conjunction with the Quality Management Medical Review.
• Responsible for addressing and forwarding fraud and abuse allegations to the Compliance.
• Department for resolution and/or assisting in the investigation in conjunction with the grievance.
• Responsible for formulating/implementing and executing all processes, requests, workflows or policies as requested by management in a courteous and efficient manner, including offering a proactive approach to suggestions and recommendations and working or cooperating with all office associates and management.
• Participates in staff meetings.
• Other job duties as assigned by management.

REQUIREMENTS & QUALIFICATIONS

• High School Diploma or equivalent.
• 1-2 years experience in appeals and grievance, utilization management, or member service preferred.
• Ability to successfully interact with providers, health plan personnel and health plan members.
• Excellent time management skills.
• Excellent organizational skills and ability to handle multiple tasks.
• Excellent verbal and written communication skills.
• Excellent proficiency in Excel, Word, and Access.
• Attention to detail and accuracy and capability of meeting deadlines consistently.
• Ability to understand and follow written and verbal instructions.
• Professional appearance and demeanor.
• Bilingual skills a plus.
• Versatility, flexibility, and a willingness to work enthusiastically within a fast paced and constantly changing environment.