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Alignment Healthcare
posted 2 months ago
About the position
The Appeals & Grievance Coordinator plays a crucial role in managing member grievances and appeals within Alignment Health. This position is responsible for the receipt, investigation, and processing of grievances and appeals, ensuring compliance with company policies and CMS guidelines. The coordinator will engage with members to acknowledge their concerns, conduct thorough investigations, and maintain accurate documentation throughout the process. This role is essential in fostering positive relationships with members and ensuring their concerns are addressed effectively.
Responsibilities
- Categorize each request type (grievances, appeals, CTM, LEP) accurately.
- Acknowledge receipt of grievances and appeals via outreach to members.
- 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 compliance with processing timeframes according to company policy and CMS guidelines.
- Prepare monthly and quarterly reports as requested and manage assigned cases timely.
- 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.
- Maintain positive relationships with plan staff, providers, members, and regulators.
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.
Benefits
- Fully remote work environment.
- Continuous learning and growth opportunities.
- Supportive company culture that encourages sharing ideas and perspectives.
