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.
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:
Conversational level of any of the threshhold languages (Spanish, Tagalog, Russian) would be ideal, but not required.
All HealthPlan employees are expected to:
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.