• Grievance Resolution Specialist

    Job Locations US-CA-Fairfield
    Job ID
    2019-1400
    Category
    Administration
  • Overview

    To manage and coordinate incoming grievances and appeals and provide administrative support for the Grievance Unit. Assesses and completes appropriate documentation for tracking and trending date, which may include conducting all pertinent research on a level one grievance in accordance with all established regulatory guidelines. Reviews delegated grievance logs and processes requests for grievance data and reporting.

    Responsibilities

    • Answers unit’s incoming calls and responds to PHC member’s inquiries accordingly.
    • Enters grievances and appeals in the Everest system. Checks Centers of Medicare & Medicaid Services (CMS) website for incoming CMS grievances and inducts grievance as appropriate.
    • Responsible for maintaining grievance information and supporting documentation in accordance with regulatory bodies for all lines of business.
    • Prepares and maintains monthly, quarterly, semi-annual, and annual reports as assigned.
    • Assigns case work to Grievance Coordinators using a rotation schedule.
    • Schedules and creates meeting material for meetings and coordinators schedules. Prepares and edits meeting minutes and meeting material.
    • Reviews PCP Transfer Report/End of Business Day Report and reports issues to the Grievance Supervisor.
    • Maintains knowledge of the current regulatory standards, internal policies and procedures, member benefits, and member materials (such as handbooks).
    • Identifies: potential HIPAA privacy issues to the Privacy Officer; potential quality issues to the Quality Improvement Department; potential issues involving Fraud, Waste, and Abuse to the Compliance Department.
    • Prints, faxes, mails, photocopies, and scans provider correspondence.
    • Processes incoming invoices of payment and obtains authorization on invoices and requisitions.
    • Identifies errors and deficiencies to management in regards to quality and compliance.
    • Assists in the creation and distribution of various project documents.
    • Participates in audits and trainings.
    • Other duties as assigned.

    Qualifications

    Education and Experience

    High school diploma or equivalent; minimum one (1) year experience in managed healthcare insurance environment, or equivalent combination of education and experience. Thorough working knowledge of managed care concepts, policies, and procedures. Ability to understand, interpret, and prepare documentation used in legal cases.

     

    Special Skills, Licenses and Certifications

    Working knowledge of business software applications. Bilingual skills in Spanish, Tagalog, or Russian may be required. Ability to understand, interpret, and prepare documentation used in legal cases. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.

     

    Performance Based Competencies

    Ability to learn quickly and acquire in-depth knowledge of software used at PHC. Computer proficiency with knowledge and experience in Microsoft Suite. Excellent oral, written, and interpersonal skills. Ability to write comprehensive statements using proper grammar and sentence structure. Attention to detail and excellent organizational skills required. Ability to prioritize issues, use good judgement skills, and handle sensitive issues with confidentiality, tact, and diplomacy. Demonstrate good analytical skills and the ability to problem solve creatively, objectively, and rapidly. Decision making, critical thinking skills required.

     

    Work Environment And Physical Demands

    More than 80% of work time is spent in front of a computer monitor. When required, the ability to lift, carry, or move objects of varying size, weighing up to 25 lbs.

     

     

     

    Additional Preferred Skills: Strong typing skills, knowledege of Microsoft Word, Excel and Outlook. 

     

     

    All HealthPlan employees are expected to:

     

    • Provide the highest possible level of service to clients;
    • Promote teamwork and cooperative effort among employees;
    • Maintain safe practices; and
    • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

     

    IMPORTANT DISCLAIMER NOTICE

     

    The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

     

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