Appeals and Grievances Coordinator

CommonSpirit Health - Bakersfield, CA

Full-time - Entry Level

Remote - Bakersfield, CA

Hospitals

About the position

The Appeals and Grievances Coordinator at Dignity Health MSO is responsible for managing and coordinating the appeals and grievance process, ensuring compliance with regulatory requirements, and facilitating timely resolution of member and provider complaints. This remote position focuses on operational, business, and regulatory activities related to health plan partnerships, aiming to enhance service quality and patient care coordination.

Responsibilities

• Receive, document, and manage member and provider appeals and grievances in accordance with DHMSO's organizational policies and regulatory standards.
• Ensure all cases are processed within required timeframes and follow-up actions are completed properly.
• Maintain detailed and accurate records of all appeals and grievances, including documentation of investigations, outcomes, and communications.
• Manage and work closely with Regulatory partners in the management of identified patient populations.
• Prepare files for appeals to regulatory agencies, staying current with all applicable regulatory requirements.
• Conduct relevant research into complaints and collaborate with various departments and external entities to collect additional information as necessary.
• Ensure all appeals and grievances are handled in compliance with federal, state, and local regulations, including CMS guidelines and health plan requirements.
• Monitor and analyze trends in appeals and grievances to identify systemic issues and recommend corrective actions.
• Prepare and submit regular reporting on appeals and grievance activity, trends, and outcomes to management and regulatory agencies as required.

Requirements

• 2+ years administrative experience in a compliance auditing arena.
• Familiarity with healthcare regulations, including HIPAA, CMS, and state-specific requirements.
• Associate's degree in relevant field or 3 years of related job or industry experience in lieu of degree.

Nice-to-haves

• Knowledge of DMHC, NCQA, CMS and other regulatory bodies preferred.
• Knowledge of HIPAA, managed care environment preferred.
• Strong technical proficiency in data analysis; database software preferred.
• 2 years managed care experience preferred.
• 1 year delegation oversight experience preferred.
• Regulatory audit experience preferred.
• Bachelor's degree in a relevant field (e.g., healthcare management, business administration, compliance) or 5 years of related job or industry experience in lieu of degree, preferred.
• Certified Compliance Professional (CCP) preferred.
• Certified Professional in Healthcare Quality (CPQH) preferred.
• Certified Healthcare Auditor (CHA) preferred.

Benefits

• Competitive pay with a flexible Health & Welfare benefits package.
• Cafeteria-style benefit program allowing choice of medical, dental, and vision plans.
• Health Spending Account (HSA).
• Life Insurance and Long Term Disability.
• 401k retirement plan with a generous employer-match.
• Paid Time Off and Sick Leave.