Grievance Coordinator

Profile

We have an opportunity to join the Alliance as a Grievance Coordinator in the Member Services Department.

We have one position available and can be filled in either our Merced or Scotts Valley office.

WHAT YOU'LL BE RESPONSIBLE FOR

Reporting to the Grievance Supervisor, you will assist in the administration and/or resolution of low complexity cases in support of the Alliance Grievance function. You will perform administrative duties to track, organize, monitor and follow up on case work. You will participate in departmental and cross departmental trainings, workgroups, and operational improvement activities

ABOUT THE TEAM

Grievance work involves complex coordination, investigation and specific resolution within regulatory timeframes. The Grievance team is organized by Member Complaint and Provider Dispute specialties. Areas of Grievance work include:

Member Complaints:

An oral or written statement submitted by a member or a member's authorized representative expressing dissatisfaction with any aspect of the Alliance's health care plan.

Expedited Complaints:

A complaint involving an imminent and serious threat to the health of the member, as determined by an Alliance Medical Director that includes, but is not limited to, severe pain, potential loss of life, limb or major bodily function.

Appeals:

A member complaint involving an Alliance Utilization Management (UM) decision.

State Fair Hearings:

The process whereby a member enrolled in Medi-Cal requests the Department of Social Services (DSS) and its Administrative Law Division to resolve Plan decisions that deny, modify or delay health care services or affect Medi-Cal benefits.

Inquiries:

A question or request for information or assistance by a member that does not reflect the member's dissatisfaction with any aspect of the Alliance's health care plan.

Complex Member/Provider Billing Issues:

When an Alliance member receives a bill from a medical provider for covered services.

Provider Disputes:

A provider's written statement of dissatisfaction regarding the Alliance's action or inaction

WHAT YOU'LL NEED TO BE SUCCESSFUL

To read the full position description, and list of requirements click here

Knowledge of:

The principles and practices of managed healthcare, healthcare coverage and benefit structures, principles of coordination of benefits and medical billing

Title 22 and Title 28 utilization management and grievance regulations

The diverse needs of the Medi-Cal population

Proper grammar, spelling, punctuation and formatting

Ability to:

Understand and communicate the complex operations and processes of the Alliance, particularly the Utilization Management, Care Management and Member Services departments

Use the Alliance's internal tracking systems

Draft professional correspondence

Education and Experience:

Associate's Degree in health, social services or a related field or Medical Assistant certification

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 or public assistance; or an equivalent combination of education and experience may be qualifying

OTHER DETAILS

While this position is connected to one of our Alliance offices, we are in a fully telecommute work environment right now due to the COVID-19 pandemic. The interview and on-boarding process for this position will be completed remotely

This position

may

require onsite presence when our offices re-open, which will be no sooner than February 1, 2022. Onsite presence will most likely be on a part-time basis, but is dependent on business needs

COVID-19 Vaccine Requirement:

This position requires staff to be fully vaccinated upon their start date as a condition of employment. Proof of vaccination must be submitted at time of hire. Fully vaccinated is defined by the CDC. This means receipt of the second dose in a 2-dose series (Pfizer & Moderna vaccines) OR receipt of a single-dose vaccine (Johnson & Johnson) AND a 2-week period having passed since the administration of the last vaccine dose.

Additionally, all positions at the Alliance are required to meet these minimum qualifications

OUR BENEFITS

Medical, Dental and Vision Plans

Ample Paid Time Off

11 Paid Holidays per year

401(a) Retirement Plan

457 Deferred Compensation Plan

Robust Health and Wellness Program

EV Charging Stations

And many more

ABOUT US

We are a group of over 500 dedicated employees, committed to our mission of providing accessible, quality health care that is guided by local innovation. We feel that our work is bigger than ourselves. We leave work each day knowing that we made a difference in the community around us.

Join us at Central California Alliance for Health (the Alliance), where you will be part of a culture that is respectful, diverse, professional and fun, and where you are empowered to do your best work. As a regional non-profit health plan, we serve over 377,000 members in Santa Cruz, Monterey and Merced counties. To learn more about us, click here

At this time the Alliance does not provide any type of sponsorship. Applicants must be currently authorized to work in the United States on a full-time, ongoing basis without current or future needs for any type of employer supported or provided sponsorship.

Company info

Central California Alliance for Health
Website : http://www.ccah-alliance.org/