Grievance and Appeals Coordinator, South San Francisco, CA
GRIEVANCE AND APPEALS COORDINATOR
The Health Plan of San Mateo (HPSM), a managed care health plan, seeks a full time Grievance and Appeals Coordinator to implement HPSM’s Grievance and Appeals processes by resolving complaints filed by HPSM members and their representatives as well as provide back-up support to Member Services and CareAdvantage units. The essential duties & responsibilities will include the following:
- Research and resolve member complaints for all lines of business ensuring compliance with HPSM’s Grievance and Appeals policies and procedures.
- Maintain grievance and appeals case files in HPSM’s data base.
- Effectively communicate with members and providers verbally and in writing.
- Prepare summaries and write resolution letters for members, which include summarizing member complaints and steps taken to resolve complaints in clear and grammatically correct language.
- Attend and present cases at bi-weekly Staff Grievance and Appeals Committee.
- Prepare files for appeals to regulatory agencies.
- Maintain current on all regulatory requirements as they apply to grievance and appeal processes.
- May, as needed, provide necessary coverage in the call centers for Member Services and CareAdvantage.
- Perform other duties as assigned.
Education and Experience: Associate’s degree in health, business, social sciences, or humanities, preferred. Two (2) years of experience working with Medi-Cal or Medicare in a managed care environment preferred. Work performing grievance and appeals processing preferred. Work in a call center, claims department, and/or other customer service position required.
Knowledge of: Medicare, Medi-Cal, Managed Care and medical terminology preferred. Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, and PowerPoint.
Ability to: Communicate effectively and professionally, both verbally and in writing. Summarize information clearly, thoroughly, and quickly in writing. Deal with difficult people and situations while providing quality customer service. Use sound judgment, identify next steps to be taken and develop appropriate solutions. Collaborate with multiple parties to solve problems; solve problems independently.
Other Requirement: Fluency in Spanish, Tagalog, Mandarin/Cantonese or other language capability is highly preferred. Starting Compensation Range: -depending on experience.
Benefits Information: Excellent benefits package offered, including HPSM paid premiums for employee’s Medical, Dental and Vision coverage. Employee pays a small portion of the dependent premiums (5%) for medical and dental benefits. Additional HPSM benefits include fully paid life, AD&D, STD, and LTD insurance; retirement plan (HPSM contributes equivalent of 10% of annual compensation); holiday and vacation pay; tuition reimbursement plan; onsite fitness center and more. Check out our full benefits package at:
Application Process: To apply, submit a resume and cover letter with salary expectations to: Health Plan of San Mateo, Human Resources Department, 801 Gateway Blvd., Suite 100, South San Francisco, CA 94080 or via email: firstname.lastname@example.org or via fax: (650) 616-8039. . The Health Plan of San Mateo is proud to be an Equal Opportunity Employer and encourages minority candidates of all backgrounds to apply. File by: Continuous until filled. EOE