Grievance and Appeals Coordinator at Roth Staffing Companies in San Jose, California

Job Description:

Ultimate Staffing is looking for a Grievance and Appeals Coordinator to join a well-established healthcare company in San Jose, CA! This is a 6 month contract, remote schedule with the ability to travel to the office in San Jose, CA at times. The schedule is M-F, 8:30am to 5pm.



The Grievance and Appeals Coordinator is responsible for the beginning-to-end process of receiving, researching and resolving of new and existing member and provider grievance and appeals cases for all lines-of-business including any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and company policies and procedures as set forth for each line of business.



ESSENTIAL DUTIES AND RESPONSIBILITIES:



To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.


1. Act as a back-up to the Grievance and Appeals Intake Specialist during times of high volume work and/or staffing shortages to ensure appropriate intake of new and existing grievance and appeal cases, assessing the priority of each case and routing to the appropriate staff.


2. Ensure grievance and appeals cases are accurate and include the necessary elements for processing and resolving, giving special attention to those identified as "Expedite". Create clear and concise documentation in applicable system(s).


3. Use good judgment and department resources to identify all issues and required actions within a case, appropriately categorize cases and identify required actions in accordance with state and federal regulations.


4. Produce and manage outbound documents, correspondence and reports in a manner that meets required timeframes.


5. Ensure adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required timeframes.


6. Prepare case files for State Fair Hearings, Independent Review Entities or other escalated types of cases, including documentation of the Statement of Position and case narratives. Represent SCFHP in any hearing proceedings.


7. Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing.


8. Contact members and providers to seek additional information or clarification regarding grievance and appeals cases and review and resolve issues by requesting medical records, notice of action, or any other pertinent information related to grievances and appeals from medical groups, delegated entities and/or providers.


9. Perform complete, accurate and consistent data entry into system software applications in accordance with policies, procedures and instruction from the Manager of Grievance and Appeals Operations.


10. Maintain case files by ensuring that they are documented in accordance with state and federal requirements and organized in a manner that adheres to SCFHP standards and audit requirements.


11. Participate in retrospective audit and review of cases and complete and correct gaps or errors in data.


12. Identify operational issues and trends with SCFHP, delegates and other external stakeholders. Communicate these issues internally and externally and assist in formulating appropriate remediation plans.


13. Assist the Manager of Grievance and Appeals Operations and peers with special projects.


Work collaboratively and cross-functionally with other departments to facilitate appropriate resolutions. Work as a team to complete departmental tasks to meet deadlines and accomplish department objectives.


14. Attend and actively participate in Grievance and Appeals Committee meetings, operational meetings and department