Grievance Coordinator

We have an opportunity for 2 Grievance Coordinators to join the Alliance as a Grievance Coordinator in the Member Services Department, based in 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
• Perform administrative duties to track, organize, monitor and follow up on case work
• 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 grievance regulations
  • Diverse needs of the Medi-Cal population
  • Customer service principles and practices
  • Microsoft Word, Outlook, OneNote and Excel
  • Conflict resolution techniques
• 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
  • Competently navigate computer systems
  • Work independently with minimal supervision and as a member of a team
• 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 INFORMATION

• We are in a hybrid work environment and we anticipate that the interview process will take place remotely via Microsoft Teams.
• While some staff may work full telecommuting schedules, attendance at quarterly company-wide events or department meetings will be expected.
• In-office or in-community presence may be required for some positions and is dependent on business need. Details about this can be reviewed during the interview process.

The full compensation range for this position is listed by location below. 

The actual compensation for this role will be determined by our compensation philosophy, analysis of the selected candidate's qualifications (direct or transferrable experience related to the position, education or training), as well as other factors (internal equity, market factors, and geographic location).