Your Role

The Appeals & Grievance Medi-Cal team performs comprehensive research related to the facts and circumstances of member complaints, appeals, and grievances. This position is required to apply contract language, benefits, and covered services in researching and providing an accurate & appropriate resolution in accordance with guidelines established by the appropriate regulators.. The Appeals & Grievance Coordinator will report to the Supervisor of the Appeals & Grievances Medi-Cal Team

Your Work

In this role, you will:

• Assist with telephone inquiries regarding member appeals
• Respond to appeals in grievances and member reconsiderations
• Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process
• Interpret and explain health plan benefits, policies, procedures and functions to members and providers
• Administer ongoing grievance tracking, trending, and reporting for assigned grievances
• Research, review, and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating in the process in accordance with DHCS and DMHC guidelines, contractual obligations, NCQA guidelines and Plan policy
• Interpret and explain health plan benefits, policies, procedures and functions to members and providers
• Provide superior customer service through developing and maintaining positive customer relations
• Communicate effectively with other departments to resolve concerns
• Assists in ongoing analytical review of cases to identify trends and provide feedback
• Generate appropriate/accurate acknowledgement and resolution letters.
• Document all relative findings and actions in all applicable systems
• Perform to standard department metrics based on established goals and objectives
• Demonstrate flexibility by working overtime which may entail weekends and/or holidays dependent on business and inventory needs
• Accountable for monitoring daily reports to ensure service timeliness and compliance is met
• Perform additional duties and projects as assigned by Management