Central Coast Hourly Rate - $26.53 - $35.89
Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.
Job Summary
The Grievance and Appeals Coordinator is responsible for facilitating member grievances, appeals, and billing issue cases. They will handle all G&A and billing issues as assigned by the Medicare G&A Manager. This position ensures timely and compliant case resolution, and navigates and utilizes internal and external resources effectively. They demonstrate comprehensive knowledge of Medicare and Medi-Cal benefits and coordination.
Duties and Responsibilities
- Conduct thorough research and provide resolutions that meet regulatory and contractual requirements, with a focus on service recovery and effective communication (especially written).
- Apply expertise in CenCal Health benefits, Medicare/Medi-Cal integration, and dual-eligibility to accurately process appeals and grievances.
- Understand and apply knowledge of copayments, coinsurance, pharmacy formulary, provider networks, and collaboration with local government and community-based organizations (CBOs).
- Maintain assigned G&A and member billing case load along with appropriate overview of G&A documentation of member grievance and appeal descriptions from Call Center teams.
- Initiate investigation, research, prepare clinical G&A packets for Quality Nurse Reviewers and Medical Directors, and resolve G&A cases that do not require clinical review for the Medicare G&A Manager’s approval.
- Provide final letters to members within mandated resolution timeframes and complete G&A packet for Grievance & QI Supervisor’s review and approval.
- Provide feedback to Member Services Call Center Managers regarding appropriate and complete documentation for the Member Grievance and Appeal System.
- Provide support and investigative assistance regarding State Fair Hearings to the Director of Member Services and Director of Legal Affairs.
- Log, research and successfully coordinate complicated Continuity and Coordination of Care Cases for members.
- Assure compliance with Health Plan’s G&A Policies and Procedures aligned with government regulations and laws.
- Provide high-level customer service through appropriate and accurate in-depth research and resolution of member grievances, appeals, and billing issues.
- Ensure timely resolution of complex cases and retroactive cases from state referrals within established and mandated service levels.
- Use reference databases efficiently to manage a high volume of cases within regulatory timeframes.
- Apply knowledge of benefit structures and applicable copayments/coinsurance when resolving member issues.
- Understand provider claim submission processes and how they impact grievances and appeals resolution.
- Research and resolve cases involving benefit interpretation and coverage under dual programs (Medicare and Medi-Cal).
- Establish and maintain effective and cooperative working relations with internal health plan departments and external agencies including CMS, DSS, Public Health Departments, Tri-Counties Regional Centers, California Children’s Services, Public Authority, Mental Health agencies, and the Social Security Administration.
- Collaborate with network providers and community-based organizations (CBOs) to support member case resolution.
- Other duties as assigned.
