To assess and complete appropriate documentation for tracking and trending data. Responsible for written responses to all incoming correspondence, including all grievances from members, providers and outside agencies as well as second level and above appeals from members and/or providers for all lines of business.
ESSENTIAL DUTIES AND RESPONSIBILITIES
– Handles outbound and incoming calls, including but not limited to discussing with member/providers/designees/regulatory agencies regarding the status of their grievance in a competent and professional manner.
– Conducts all pertinent research in order to evaluate, respond, and close incoming grievances accurately, timely, and in accordance with all established regulatory guidelines.
– Processes and appropriately resolves assigned grievances including complaints, appeals, and state hearings within mandated time frames.
– Proposes recommendations and seeks decisions as it relates to all grievances and appeals through internal and external communication with other departments in PHC, medical personnel, and outside agencies.
– Maintains grievance information and supporting documentation in accordance with regulatory bodies for all lines of business.
– Prepares CGA case files and conducts self-audits of work to ensure quality and compliance.
– Identifies and forwards potential issues to the appropriate department.
– Supports and participates in process improvements, implementation of new processes, trainings, etc.
– Maintains data and processes reports regarding grievances as necessary for regulatory, internal, and external reporting requirements.
– Provides backup for other grievance staff during time of absence as directed.
– Other duties as assigned.
MINIMUM HIRING CRITERIA
Education and Experience
Bachelor’s degree in Healthcare Administration or four (4) years of related experience.
Special Skills, Licenses and Certifications
Thorough working knowledge of managed care concepts, policies and procedures, including but not limited to knowledge of grievance and appeal regulations. Ability to understand, interpret and prepare documentation used in legal cases. Strong knowledge of Microsoft Word, Excel, and Outlook. Proficiency with SharePoint and Essette. Bilingual in Spanish may be required. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Performance Based Competencies
Demonstrates a working knowledge of all operating systems used in the grievance unit, including the grievance case management system, Everest. Practice the philosophy of Honest, Direct and Respectful (HDR) Communication with all PHC staff and members/providers/designs. Demonstrates a working knowledge of
applicable regulatory standard and internal policies and procedures.
Work Environment And Physical Demands
Ability to use a computer keyboard. More than 70% of work time is spent in front of a computer monitor. When required, ability to move carry or lift objects weighing up to 25 lbs.
All HealthPlan employees are expected to:
– Provide the highest possible level of service to clients;
– Promote teamwork and cooperative effort among employees;
– Maintain safe practices; and
– Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.