Appeals/Grievance Coordinator I - SHP Operations - Remote - Day Shift - Full Tim
Sharp Health Plan, San Diego
Appeals/Grievance Coordinator I - SHP Operations - Remote - Day Shift - Full Time
Join to apply for the Appeals/Grievance Coordinator I - SHP Operations - Remote - Day Shift - Full Time role at Sharp Health Plan
Appeals/Grievance Coordinator I - SHP Operations - Remote - Day Shift - Full Time
Join to apply for the Appeals/Grievance Coordinator I - SHP Operations - Remote - Day Shift - Full Time role at Sharp Health Plan
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Hours
Shift Start Time:
Variable
Shift End Time
Variable
AWS Hours Requirement
8/40 - 8 Hour Shift
Additional Shift Information
Weekend Requirements:
As Needed
On-Call Required
No
Hourly Pay Range (Minimum - Midpoint - Maximum)
$29.410 - $36.760 - $44.110
The stated pay scale reflects the range that Sharp reasonably expects to pay for this position. The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicants years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.
What You Will Do
Responsible for the investigation, documentation and resolution of Commercial member appeals and grievances in compliance with State law, rules, and guidelines; provider and group agreements; Operations Manual; benefit matrices; and other administrative and medical guidelines, policies, and procedures. Works closely with the Chief Medical Officer (CMO) who is responsible for all decisions regarding clinical appeals and grievances and the Chief Operations Officer (COO) who is responsible for non-clinical appeals and grievances.
Required Qualifications
- 3 years' experience in claims, utilization review, appeals or member services in a managed care environment.
- Bachelor's degree in business administration or health care administration (including courses of study in accounting, finance, marketing, and health care administration).
- Appeal and Grievance Processing Under limited supervision, reviews and responds to appeals and grievances received from Commercial members and providers, in accordance with applicable policies and procedures. Ensures compliance with all required timeframes for acknowledgement and resolution of appeals and grievances. Ensures that policies and procedures, letters and member materials regarding appeals and grievances are in compliance with state and federal legal and regulatory requirements and NCQA accreditation standards.
- Case Files and Documentation Prepares and maintains case files and database for appeals and grievances in accordance with SHP and DMHC requirements and NCQA accreditation standards. Maintains appropriate documentation in department database to ensure accurate and thorough documentation of appeals/grievance process. Communicates both in written and oral form in a professional manner with members, providers, other health plan departments, and representatives of regulatory agencies.
- Customer Service Provides prompt, accurate and excellent services to internal and external customers. Develops solid professional working relationships with various internal departments, units and, as required, vendors, providers, employers, brokers and/or other customers.
- General Support Participates in special projects and other duties as assigned. These may include, but are not limited to, work groups, proposals, audits and back-up support for other departments.
- Audits and Workgroups Supports Plan in Commercial regulatory and accreditation audits. Pulls case files, completes quality review of documents and data files, participates in audit interviews to describe Plan appeal and grievance processes. Participates in Plan workgroups as assigned. Provides feedback on issues and trends identified in member appeals and grievances.
- Reports Prepares reports on grievance and appeals as required by regulatory agencies, NCQA standards, and Plan management. Prepares weekly reports on open cases.
- Research Conducts research between different departments in order to resolve issues involving medical groups, providers, employer groups, DHS, CMS, DMHC, and members by utilizing all documentation necessary. Establishes and maintains positive working relationships with internal departments and delegated entities to facilitate communication and follow-up.
- Thorough understanding of managed care principles and models.
- Thorough understanding of health services and delivery models, including hospital, physician, ancillary, home health, prescription drugs, etc. Knowledge of various managed care reimbursement methodologies.
- Ability to analyze and interpret data and prepare summary reports from findings.
- Familiarity with DMHC, CMS, and other regulatory agency and accreditation standards related to Commercial appeals and grievances.
- High level of integrity, ethical practices, innovative thinking, ability to exercise sound judgment and maintain confidentiality.
- Able to exercise mature and sound judgment in the commitment of the Plan's mission and operating goals.
- Exceptional diplomacy skills to effectively resolve issues under sometimes tense and stressful circumstances.
- Able to follow strict timelines and manage multiple tasks concurrently.
- Ability to be flexible.
- Able to work independently and as a member of a cohesive, results-oriented team.
- Excellent organizational and interpersonal skills.
- Computer skills must include experience with electronic mail, word processing, spreadsheets, and internet research.
- Adept in both written and oral communications. Strong writing skills.
Seniority level
Seniority level
Mid-Senior level
Employment type
Employment type
Full-time
Job function
Job function
Other-
Industries
Hospitals and Health Care
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Appeals/Grievance Coordinator I - SHP Operations - Remote - Day Shift - Full Time
Appeals/Grievance Coordinator I - SHP Operations - Remote - Day Shift - Full Time
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