Grievance Coordinator

We have an opportunity to join the Alliance as a Grievance Coordinator in the Member Services Department. This position will require in office presence in our Merced or Scotts Valley office (hybrid).

WHAT YOU'LL BE RESPONSIBLE FOR

Reporting to the Grievance Supervisor, this position:

• Assists in the administration and resolution of low complexity cases in support of the Alliance Grievance function


• Performs administrative duties to track, organize, monitor, and follow up on case work


• Participates in departmental and cross-departmental trainings, workgroups, and operational improvement activities


• Performs other duties as assigned

ABOUT THE TEAM

Grievance work involves complex coordination, investigation and specific resolution(s) within regulatory timeframes.  Areas of Grievance work include:

• Appeals: A member complaint involving an adverse benefit determination by an Alliance Utilization Management (UM) decision.


• Member Grievances (Complaints): An oral or written statement submitted by a member or a member's authorized representative expressing dissatisfaction with any aspect of the Alliance's health care plan.


• Expedited Appeals/ Grievances: A complaint or Appeal involving an imminent and serious threat to the health of the member, as determined by an Alliance Medical Director that includes, but is not limited to, severe pain, potential loss of life, limb or major bodily function.


• State Fair Hearings: The process whereby a member enrolled in Medi-Cal requests the Department of Social Services (DSS) and its Administrative Law Division to resolve Plan decisions that deny, modify or delay health care services or affect Medi-Cal benefits.


• Inquiries: A question or request for information or assistance by a member that does not reflect the member's dissatisfaction with any aspect of the Alliance's health care plan.


• Complex Member Billing Issues or Member Reimbursements: When an Alliance member receives a bill from a medical provider for covered services or paid out of pocket for covered Medi-Cal services.

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description, and list of requirements click here.

• Knowledge of:




• Principles and practices of managed healthcare, healthcare


• Coverage and benefit structures, principles of coordination of benefits and medical billings


• Title 22 and Title 28 utilization management and grievance regulations


• The diverse needs of the Medi-Cal population


• Customer services principles and practices 




• Ability to:
  
  
  
  • Understand and communicate the complex operations and processes of the Alliance, particularly the Utilization Management, Care Management, and Member Services departments
  
  
  • Use the Alliance's internal tracking systems
  
  
  • Draft professional correspondence
  
  
  • Learn and utilize computer systems and verbally communicate the program mission, vision, and roles
  
  
  
  


• Education and Experience:
  
  
  
  • Associate's degree in health, social services or a related field and one year of experience in a managed health care setting, health plan, or provider office interacting with members, patients, or providers and receiving complaints, preferably related to healthcare administration or public assistance; or an equivalent combination of education and experience may be qualifying
  
  
  
  

OTHER INFORMATION

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.


• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.


• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

The full compensation range for this position is listed by location below. 

The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).

Typical areas in Zone 1: Bay Area, Sacramento, Los Angeles area, San Diego area

Typical areas in Zone 2: Fresno area, Bakersfield, Central Valley (with the exception of Sacramento), Eastern California, Eureka area

OUR BENEFITS 

Available for all regular Alliance employees working more than 30 hours per week. Some benefits are available on a pro-rated basis for part-time employees. These benefits are unavailable to temporary employees while on an assignment with the Alliance.

• Medical, Dental and Vision Plans


• Ample Paid Time Off 


• 12 Paid Holidays per year


• 401(a) Retirement Plan


• 457 Deferred Compensation Plan


• Robust Health and Wellness Program


• Onsite EV Charging Stations

ABOUT US

We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us. 

Join us at Central California Alliance for Health (the Alliance), where you will be part of a culture that is respectful, diverse, professional and fun, and where you are empowered to do your best work. As a regional non-profit health plan, we serve members in Mariposa, Merced, Monterey, San Benito and Santa Cruz counties. To learn more about us, take a look at our Fact Sheet.

The Alliance is an equal employment opportunity employer. Qualified applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), sexual orientation, gender perception or identity, national origin, age, marital status, protected veteran status, or disability status. We are an E-Verify participating employer

At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.