Appeal/Grievance Coordinator- SHP- Full Time- Telecommuter - California, United States - Sharp Corporation

Description

Appeal/Grievance Coordinator- SHP- Full Time- Telecommuter page is loaded Appeal/Grievance Coordinator- SHP- Full Time- Telecommuter Apply locations Health Plan-Telecommuter time type Full time posted on Posted 2 Days Ago job requisition id JR145924 Hours
Shift Start Time:8:30 AM
Shift End Time:5 PM

Additional Shift Information:

Weekend Requirements:
No Weekends On-

Call Required:
No Hourly Pay Range (Minimum

• Midpoint

- Maximum):$ $ $41.979 The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.

The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicants years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

What You Will DoResponsible for the investigation, documentation and resolution of member appeals and grievances in compliance with State law, rules, and guidelines; provider and group agreements; Operations Manual; benefit matrices; and other administrative and medical guidelines, policies, and procedures.

Works closely with the Chief Medical Officer (CMO) who is responsible for all decisions regarding clinical appeals and grievances and the Chief Operations Officer (COO) who is responsible for non-clinical appeals and grievances.

Required Qualifications 3 Years Experience in claims, utilization review, appeals or member services in a managed care environmentPreferred Qualifications Bachelor's Degree Business Administration or Health Care Administration (including courses of study in accounting, finance, marketing, and health care administration)Essential FunctionsAppeal and grievance processingUnder limited supervision, reviews and responds to appeals and grievances received from members and providers, in accordance with applicable policies and procedures.

Ensures compliance with all required timeframes for acknowledgement and resolution of appeals and grievances.

Ensures that policies and procedures, letters and member materials regarding appeals and grievances are in compliance with DHS, CMS,and DMHC requirements and NCQA accreditation standards.

Case files and documentation.

Prepares and maintains case files and database for appeals and grievances in accordance with SHP, DHS, CMS, and DMHC requirements and NCQA accreditation standards.

Maintains appropriate documentation in IDX Customer Service Module to ensure accurate and thorough documentation of appeals/grievance process.

Communicates both in written and oral form in a professional manner with members, providers, other health plan departments, and representatives of regulatory agencies.

Customer serviceProvides prompt, accurate and excellent services to internal and external customers.

Develops solid professional working relationships with various internal departments and units and, as required, vendors, providers, employers, brokers and/or other customers.

General supportParticipates in special projects and other duties as assigned. These may include, but are not limited to, work groups, proposals, audits and back-up support for other departments.

Member inquiry workgroupChairs the Member Inquiry Workgroup and, with the other Workgroup participants, reviews the documentation and resolution of member inquiries and requests for assistance.

Provides feedback to Customer Service, Enrollment, Provider Relations, Claims Research, and Health Services on issues and trends identified in the Member Inquiry Workgroup.

ReportsPrepares reports on grievance and appeals as required by regulatory agencies, NCQA standards,and Plan management. Prepares weekly reports on open cases.

ResearchConducts research between different departments in order to resolve issues involving medical groups, providers, employer groups, DHS, CMS, DMHC, and members by utilizing all documentation necessary.

Establishes and maintains positive working relationships with internal departments and delegated entities to facilitate communication and follow-up.
Knowledge, Skills, and Abilities Thorough understanding of managed care principles and models.
Thorough understanding of health services and delivery models, including hospital, physician, ancillary, home health, prescription drugs, etc. Knowledge of various managed care reimbursement methodologies.
Ability to analyze and interpret data, and prepare summary reports from findings.
Familiarity with DMHC, DHS, CMS, and other regulatory agency standards related to appeals and grievances.
High level of integrity, ethical practices, innovative thinking, ability to exercise sound judgment and maintain confidentiality.
Able to exercise mature and sound judgment in the commitment of the Plan's mission and operating goals.
Exceptional diplomacy skills to effectively resolve issues under sometimes tense and stressful circumstances.
Able to follow strict timelines and manage multiple tasks concurrently.
Flexible.
Able to work independently and as a member of a cohesive, results-oriented team.
Excellent organizational and interpersonal skills.
Computer skills must include experience with electronic mail, word processing, spreadsheets, database programs and the IDX Managed Care application. Familiarity with Internet preferred.
Adept in both written and oral communications.
Strong writing skills.
Sharp HealthCare is an equal opportunity/affirmative action employer.

All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected classSharp HealthCare is a not-for-profit health care system based in San Diego, California, with four acute care hospitals, three specialty hospitals, three medical groups and a health plan.

We provide medical services in virtually all fields of medicine, including primary care, heart care, cancer, orthopedics, womens health, rehabilitation, robotic surgery and bariatric surgery.

Sharp sets the community standard for exceptional care.

Sharp Grossmont Hospital and Sharp Memorial Hospital have received prestigious Magnet recognition by the American Nurses Credentialing Center for excellence in nursing practices and quality patient care.

At the heart of our organization are more than 18,000 affiliated physicians, nurses, staff and volunteers who are on a journey to make health care better for our patients and their families.

Its what we call The Sharp Experience treating each person with dignity, compassion and respect, and using our clinical excellence and advanced technology to deliver the highest-quality patient care.

We are dedicated to transforming the health care experience by making Sharp the best place to work, the best place to practice medicine and the best place to receive care in San Diego.

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