Grievance and Appeals Coordinator I

Grievance and Appeals Coordinator I

The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Grievance and Appeals Coordinator I to implement HPSM’s Grievance and Appeals processes by resolving complaints filed by HPSM members and their representatives as well as provide back-up support to Member Services and CareAdvantage units.

The essential duties and responsibilities will include the following: 

• Research and resolve member complaints for all lines of business ensuring compliance with HPSM’s Grievance and Appeals policies and procedures.
• Maintain grievance and appeals case files in HPSM’s database.
• Effectively communicate with members and providers verbally and in writing.
• Prepare summaries and write resolution letters for members, which include summarizing member complaints and steps taken to resolve complaints in clear and grammatically correct language.
• Attend and present cases at bi-weekly Staff Grievance and Appeals Committee.
• Prepare files for appeals to regulatory agencies.
• Maintain current on all regulatory requirements as they apply to grievance and appeal processes.
• May, as needed, provide necessary coverage in the call centers for Member Services and CareAdvantage.
• Perform other duties as assigned

Requirements

Education and Experience: Associate’s degree in health, business, social sciences, or humanities, preferred. Two (2) years of experience working with Medi-Cal or Medicare in a managed care environment preferred. Work performing grievance and appeals processing preferred. Work in a call center, claims department, and/or other customer service position required

Knowledge of: Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint. Medicare, Medi-Cal, Managed Care and medical terminology preferred.

Ability to: Work cooperatively with others. Work as part of a team and support team decisions. Communicate effectively, both verbally and in writing. Adapt to changes in requirements/priorities for daily and specialized tasks communicate effectively and professionally, both verbally and in writing. Summarize information clearly, thoroughly, and quickly in writing. Deal with difficult people and situations while providing quality customer service. Use sound judgment, identify next steps to be taken and develop appropriate solutions. Collaborate with multiple parties to solve problems; solve problems independently.

Compensation and Benefits

Starting Compensation Range: - Depending on Experience

Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage.  Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits.  Additional HPSM benefits include fully paid life, AD&D, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more.