Appeals & Grievance Coordinator (Temporary) at Alignment Healthcare USA, LLC in Orange, California

Job Description:

The Grievance and Appeals Coordinator is responsible for receiving, researching and resolving of new and existing member and provider grievance and appeals cases. These cases MAY including escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements.

Job Duties and responsibilities

To perform this job successfully, an individual must be able to perform each:

• 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).

• Identify all issues and required actions within a case, appropriately categorize cases and identify required actions in accordance with state and federal regulations.

• Create and manage documents, correspondence and reports in a manner that meets required timeframes.

• 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.

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

• 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.

• 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.

• 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.
• Perform other related duties as required or assigned.