Appeals & Grievance Coordinator

Job not on LinkedIn

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $44.8k - $67.2k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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Alignment Health

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 2013

⚕️ Healthcare Insurance

🛡️ Insurance

🏥 Healthcare

💰 $135M Series C on 2020-03

Healthcare Insurance • Insurance • Healthcare

Alignment Health is dedicated to providing comprehensive care for Medicare members, emphasizing the needs of seniors, the chronically ill, and those who are frail. With a mission to transform senior healthcare, Alignment Health leverages a tailored care model and advanced technology to deliver high-quality, low-cost healthcare services. Their 24/7 concierge care team collaborates with trusted local providers to ensure that every member receives personalized care, reflecting the company's commitment to treating all members as valued family members.

📋 Description

• Track and trend all grievances, appeals, and complaints received within the Member Services Department • Act as the primary investigator and contact person for member and provider grievances and appeals • Acknowledge receipt of grievances, appeals, and CTM complaints • Gather relevant information and determine appropriate resolutions according to policies and procedures • Notify appropriate parties of resolutions and ensure internal processes are completed • Compose written correspondence to members according to plan policy and CMS Guidelines • Conduct unbiased, accurate, timely, and comprehensive investigations • Document all actions taken to resolve grievances and appeals • Ensure processing adheres to CMS guidelines and plan policy • Prepare case files for Medical Director and external reviews, including IRE review • Prepare case histories for committee and Board of Directors meetings • Maintain complete and timely grievance and appeal documentation • Prepare monthly and quarterly reports • Identify training opportunities and system or process improvements • Participate in policy and procedure reviews, CMS audit preparations, and regulator meetings/interviews • Perform other duties as assigned

🎯 Requirements

• Two years’ experience in data entry and general office background • Three years of customer service experience • Minimum 1 year Member Services or similar experience • High School Diploma or GED • Knowledge of MediCal and Medicare Managed Care Plans • Ability to keyboard/type 40+ words per minute • Ability to use the 10-key by touch • Effective written and oral communication skills • Ability to establish and maintain constructive relationships with diverse members, management, employees and vendors • Ability to read and interpret safety rules, operating and maintenance instructions and procedure manuals • Ability to write routine reports and correspondence • Ability to speak effectively before groups of customers or employees • Ability to perform basic arithmetic using American money and weight, volume and distance measurements • Effective problem-solving, organizational and time-management skills • Ability to work in a fast-paced environment • Must be available to work weekends

🏖️ Benefits

• Fully remote work • Opportunity for growth and innovation • Reasonable accommodations for individuals with disabilities • Equal opportunity employment