Appeals & Grievance Coordinator

Alignment Healthcare - Orange, CA

Full-time

Orange, CA

Professional, Scientific, and Technical Services

About the position

The Appeals & Grievance Coordinator at Alignment Healthcare USA, LLC is responsible for managing the receipt, investigation, and processing of member grievances and appeals. This role involves ensuring accurate categorization of requests, timely communication with members, and adherence to compliance guidelines while maintaining a professional relationship with all stakeholders.

Responsibilities

• Categorize each request type (grievances, appeals, CTM, LEP) accurately.
• Acknowledge receipt of grievances and appeals to members and set expectations on resolution timeframes.
• Ensure timely follow-up on medical records requests and information needed for investigations.
• Conduct non-biased investigations to determine appropriate resolutions based on plan benefits and policies.
• Create written correspondence notices for members and authorized parties according to plan policy.
• Prepare comprehensive case histories for clinical and administrative review, including IRE case submissions.
• Maintain accurate documentation of all case interactions in the plan's database.
• Adhere to processing timeframes according to company policy and CMS guidelines.
• Prepare monthly and quarterly reports as requested and manage assigned case workloads.
• Answer incoming calls from the Appeals & Grievance phone queue.
• Participate in the review and update of grievance/appeal policies and procedures to meet legal and CMS requirements.

Requirements

• High school diploma or GED required.
• Minimum of 3 years' experience in grievances and appeals, claims, or customer service.
• Knowledge of Medi-Cal or Medicare Managed Care Plans.

Nice-to-haves

• Bi-lingual (English/Spanish) preferred.