Appeals and Grievance Coordinator- Bakersfield 1.2

Description

Employment Details:

Location: Bakersfield, CA. (Onsite)

Classification: Full-Time 

This position is non-exempt and will be paid on an hourly basis.

Schedule: Monday-Friday 8am-5pm

Benefits:

· Medical 

· Dental 

· Vision 

· Paid Time Off (PTO)

· Floating Holiday 

· Simple IRA Plan with a 3% Employer Contribution

· Employer Paid Life Insurance

· Employee Assistance Program

Compensation: The initial pay range for this position upon commencement of employment is projected to fall between $26.00 and $32.49. However, the offered base pay may be subject to adjustments based on various individualized factors, such as the candidate's relevant knowledge, skills, and experience. We believe that exceptional talent deserves exceptional rewards. As a committed and forward-thinking organization, we offer competitive compensation packages designed to attract and retain top candidates like you.

Position Summary:

The Appeals and Grievances (A&G) Coordinator is responsible for supporting the end-to-end A&G process, including the intake, tracking, and resolution of member and provider complaints and appeals. This position handles low complexity cases and performs administrative tasks such as organizing case documentation, monitoring deadlines, and ensuring timely follow-up. The

A&G Coordinator collaborates with internal departments to resolve issues related to member eligibility, benefits, claims, utilization management, and pharmacy decisions. This role also involves training sessions and cross-functional work groups aimed at improving operational efficiency and service quality.

Requirements

Job Duties and Responsibilities:

• Supporting and participating in process improvements, system enhancement testing, new process implementations and documenting adjustments as requested.

• Maintaining appeal and grievance data through tracking mechanisms and processing case requests as necessary to support regulatory, internal or external requirements including

audits.

• Performs administrative duties to track, organize, monitor and follow-up on case work with duties including, but not limited to: Receiving, opening, tracking and routing Appeal and Grievance mail, faxes, email, voicemail and case correspondence.

• Reviewing Appeal and Grievance correspondence and case requests.

• Create new cases in the health plan appeals and grievances tracking application along with scanned documentation where applicable.

• Intaking, entering, tracking and updating State Fair Hearing (SFH) notices and informing

Grievance staff assigned to SFH’s of any updates, along with providing administrative support during scheduled SFH’s.

• Track appeal requests to the Livanta BFCC-QIO, an independent reviewer, to extend Health plan member covered services.

• Providing outreach to members and provider inquiries and requests through a variety of methods including phone, fax, web, and written correspondence.

• Engages in departmental and cross-departmental training, workgroups, and operational improvement activities, with duties that include but are not limited to: Attending Grievance and Appeals Committee meetings and preparing and presenting agenda items

for committee as approved or assigned by Grievance/Appeal Leadership.

• Attending monthly Department meetings and preparing and presenting agenda items for the Department as assigned by Grievance/Appeal Leadership.

• Participating in cross-departmental work groups, grievance system trainings and initiative meetings as assigned.

• Sharing information from workgroups and initiatives with the Grievance/Appeal Team during weekly Team meetings.

• Performs other duties as assigned.

Qualifications:

• Associate’s degree in health, social services or a related healthcare or equivalent work experience in related healthcare preferred.

• One year of experience in a managed health care setting, health plan, or provider office.

• Interacting with members, patients, and/or providers and experience with receiving complaints, preferably related to healthcare administration.

Key Skills and Knowledge:

• Bilingual (English/Spanish) preferred.

• Working knowledge of customer service principles and practices.

• Working knowledge of the principles and practices of managed healthcare, healthcare coverage and benefit structures, principles of coordination of benefits and medical billing.

• Working knowledge of and proficiency in Microsoft Word, Outlook, Acrobat Adobe and Excel.

• Possess a practical understanding of research methods, analysis techniques, and reporting processes.

• Capability to conduct telephone interviews in a confidential and sensitive manner effectively.

• Working knowledge of conflict resolution techniques.

• Ability to address sensitive or challenging issues with tact and diplomacy.

• Proficiency in listening, de-escalation techniques, and critical thinking skills.