Job Details

Grievance & Appeals Resolution Process Representative

Represents PHC in the Grievance & Appeals Resolution process. Responsible for reviewing, investigating, and resolving assigned member grievance and appeal cases ranging from low to high complexity. Works to transform member dissatisfaction into member satisfaction. Oversees the investigative process ensuring casework complies with DHCS guidelines, NCQA standards, and PHC best practices. Works independently, provides leadership on each investigation, prioritizes case deliverables, remains customer-focused, and stays current on changes in the healthcare system that may trigger member dissatisfaction.

Responsibilities

1. Independently determines best resolution on assigned cases, incorporating clinical guidance from PHC Medical Directors and Grievance & Appeal Nurse Specialists.
2. Investigates member-disputes of denied benefits/services, collects new evidence, reassesses for coverage, executes final decisions, and communicates it to all stakeholders.
3. Investigates member-reported concerns about dissatisfactory experiences while seeking care. Identifies facts, surveys the health care system, corrects root causes, and communicates outcomes to all stakeholders.
4. Communicates with members throughout the investigation, offers customer-focused solutions, and practices exemplary customer service to all stakeholders. Frequent contact with internal departments, providers, third party administrators, and/or regulators.
5. Manages assigned cases so they are completed within DHCS timeframes, according to G&A Desktop procedures, and/or as directed by management.
6. Documents all casework activity thoroughly, accurately, timely, and ethically.
7. Writes DHCS and NCQA compliant letters to members and providers.
8. Provides leadership to the grievance support team to complete sub-components of the investigation process.
9. Effective communicator in all modes of communication (e.g., written, verbal).
10. Knows all PHC Medi-Cal benefits or has the ability to master understanding of all benefits. Maintains knowledge of PHC Medi-Cal Handbook, PHC Policy & Procedures, and DHCS guidelines affecting benefits.
11. Identifies systematic or recurring issues that create barriers to high quality healthcare and reports them to leadership.
12. May serve as backup to absent Grievance & Appeals Case Analyst(s).
13. Attends meetings as needed including but not limited to Case Conferences, Case Forum Meetings, Department Meetings, and Division Meetings.
14. Other duties as assigned.

Qualifications

Education and Experience

Bachelor's degree or four (4) years of related work experience, preferably in Grievances & Appeals, health care customer service, case management or health plan operations.

Special Skills, Licenses, and Certifications

Ability to solve problems, be a critical thinker and detail oriented. Familiar with managed care concepts, operations, policies and procedures, including but not limited to knowledge of grievance and appeal regulations. Strong knowledge of Microsoft Word, Excel, and Outlook. Bilingual skills in Spanish, Tagalog, or Russian preferred, but not required.

Performance Based Competencies

Excellent oral and written communication skills. Ability to exercise discretion and independent judgment. Must be able to handle multiple tasks and meet deadlines. Strong organizational skills with ability to prioritize work. Must be able to work in a fast-paced environment, work well under pressure, and maintain professional composure when interacting with all stakeholders, including members.

Work Environment and Physical Demands

Daily use of telephone and computer. More than 70% of work time is spent in front of a computer monitor. Standard cubical workstation. 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 amended.

Hiring Range:

$72,364.92 - $90,456.15

Important Disclaimer Notice:

The job duties, elements, responsibilities, skills, functions, experience, educational factors, and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.