Alignment Health is revolutionizing health care for seniors by leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?
At Alignment Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.
Appeals & Grievance Coordinator
Summary
The Appeal & Grievance Coordinator is responsible for the receipt, investigation and processing of member grievances and appeals.
Essential Duties and Responsibilities
Essential duties and responsibilities include but are not limited to:
- Responsible for the appropriate and accurate categorization of each request type (grievances, appeals, CTM, LEP) received.
- Acknowledges receipt via outreach to member to inform of receipt and help set expectations on resolution timeframes.
- Responsible for ensuring medical records requests and information needed to investigate the members’ concerns are followed up with and received timely.
- Uses all tools and resources to conduct non-biased investigations of all the facts to determine the appropriate resolution per plan benefit coverage rules and department policy and procedures.
- Creates written correspondence notices for members/authorized parties in accordance with plan policy.
- Prepare clear, objective, accurate and comprehensive case histories for clinical /administrative review, including but not limited to IRE case submission.
- Maintains accurate and timely documentation of all case interactions/actions
taken in the plan’s database, including complete case files of all assigned
workload.
- Adheres to and maintains compliance with all processing timeframes according to
company policy and in accordance with CMS guidelines.
- Prepare monthly and quarterly reports as requested, ensures timely case
management of work assigned.
- Answers all incoming calls from the Appeals & Grievance phone queue.
11.Participate in periodic review and update of grievance/appeal policies and procedures to reflect appropriate legal and CMS requirements including but not limited to periodic CMS Audit preparations and regulator meetings/interviews.
- Maintain a positive and professional relationship with plan staff, providers,
members, and regulators.
- Other duties as assigned.
Supervisory Responsibilities
None.
Qualifications
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Education and/or Experience: High school diploma or general education degree (GED)
- Certificates, Licenses, Registrations: None required.
- Other Qualifications:
- Knowledge of Medi-Cal or Medicare Managed Care Plans.
- Minimum of 3 years’ experience working in grievances and appeals, claims, or customer service; or any combination of education and experience which would provide an equivalent background
- Bi-lingual (English/Spanish) preferred.
Skills and Abilities
- Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
- Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10’s and 100’s. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
- Reasoning Skills: Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
- Computer Skills: Strong computer skills.
- Other Skills and Abilities:
- Excellent communication skills.
- Excellent written skills
- Critical thinker.
- Excellent data entry.
- Strong organizational skills.
- Type 40+ words per minute.
- Experience with 10-key by touch.
Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).
Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.
*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.
