STAGE DEV MAY, 2013

Careers

Located in the heart of San Francisco’s Chinatown/Financial district, Chinese Hospital has provided health care services for the community since 1899.  The community based hospital is the last remaining independent, private hospital in San Francisco. Chinese Hospital is completing the building of the next generation campus with expanded services including additional surgical suites, new ICU and a new Skilled Nursing Facility and a new diagnostic imaging center. Chinese Hospital also operates neighborhood clinics located in the Financial district, Sunset district, Excelsior district and Daly City providing primary care and other clinical services in a team based environment.

Established in 1986, Chinese Community Health Plan (CCHP) is the health plan subsidiary of Chinese Hospital. Our mission is to improve the health of our community by delivering high-quality, affordable healthcare through culturally competent and linguistically appropriate services. CCHP offers coverage to Large Employer Groups, Individuals & Families and Small Employer Groups (on and off the insurance exchange). CCHP also offers a Medicare Advantage HMO and Dual Eligible Special Needs Plan.

Together, Chinese Hospital & Clinics, CCHP and Jade Health Care Medical Group make up an Integrated Delivery System.  If you want to help improve community health in a collaborative team-oriented environment, CHA & CCHP is the right place for you.  We offer a competitive benefits package and a great place to work.

If you want to help improve community health in a collaborative team-oriented environment, CCHP is the right place for you. Interested candidates may contact Lydia Chan at 1-415-677-2490, or email LydiaC@chasf.org.


Job Title: CCHP Grievance and Appeal Coordinator

Position Summary

This position is responsible for supporting the member Grievances and Appeals (GA) process.

Essential Duties and Responsibilities

  1. Receives information from the Member Services Department and Provider Relations
  2. Research, analyze and resolve member complaints for Commercial and Medicare lines of business and ensure compliance with state and federal regulatory requirements and CCHP’s grievance and appeal policies and procedures.
  3. Maintain grievance and appeal case files in CCHP’s Access database
  4. Prepare summaries and write resolution letters for members (and in some cases providers), which include summarizing member complaints, steps taken to resolve the complaints and plan’s determination in clear and grammatically correct language.
  5. Effectively communicate with members and providers, verbally and in writing.
  6. Obtains additional information including but not limited to responses from providers, medical records, claims, authorizations or Member Services notes.
  7. Present files to appropriate department and to the Quality Improvement Manager, Director of Clinical Services and/or Medical Director with all information collected that is needed to resolve the issue
  8. Prepare resolution letter and send to appropriate parties and regulatory agencies when case is completed or closed.
  9. Prepare quarterly reports for the Quality Improvement Committee, the Centers for Medicare and Medicaid Services and the Department of Managed Health Care relating to grievances and appeals.
  10. Maintain monthly matrix of case files and closely monitor timeframes to comply with all state and federal regulatory requirements
  11. Notifies Quality Improvement Manager of approaching report deadlines
  12. Participate in regulatory and accreditation audits
  13. Perform other duties and special projects as assigned by QI Manager, Director of Pharmacy, Quality and Health Management (PQHM) and Medical Director

Qualifications

  • Undergraduate degree, preferably in health care administration, business or a related field and any equivalent combination of education, industry training and directly related health care work experience
  • Medical Terminology and/or claims experience preferred

Skills and Abilities

  • Demonstrate strong analytical and decision-making skills
  • Ability to identify issues, recommend and implement solutions
  • Flexibility, adaptability, creativity, initiative, team player skills, and strong work ethics
  • Strong customer service skills. Ability to establish and maintain productive business relationships, manage conflict and negotiate solutions
  • Time management and organizational skills, including the ability to prioritize concurrent projects and activities, meet deadlines and work under time constraints
  • Proficiency in Word, Excel and Access
  • Excellent verbal and written communication skills in English and Cantonese.
  • Able to communicate with physicians and health care providers
  • Problem solving capability and teamwork skills
  • Prioritizes activities with minimum supervision, multitasks efficiently

Compliance Requirements

The above complies with CCHP Compliance Handbook including Code of Ethics and all statutes, accreditation standards, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.