Brief job information:
This position is responsible for supporting the member Grievances and Appeals (GA) process including responding to and resolving all verbal and written complaints from members and/or providers relating to member concerns, eligibility and benefits, claims processing, utilization management decisions, and pharmacy decisions.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Receives information from the Member Services Department, CCHP website, mail, pharmacy department and/or regulatory agencies
- Research, analyze and resolve member complaints for all lines of business and ensure compliance with state and federal regulatory requirements and CCHP’s grievance and appeal policies and procedures. Assists with the management of third party administrator and/or medical groups in investigation and research when applicable.
- Maintain grievance and appeal case files in CCHP’s database
- 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.
- Effectively communicate with members and providers, verbally and in writing.
- Obtains additional information including but not limited to responses from providers, medical records, claims, authorizations or Member Services customer service call logs.
- Present files to appropriate department and to the Quality Improvement Director, Director of Clinical Services and/or Medical Director with all information collected that is needed to resolve the issue
- 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.
- Maintain monthly matrix of case files and closely monitor timeframes to comply with all state and federal regulatory requirements
- Notifies Provider Relations Manager of approaching report deadlines
- Participate in regulatory and accreditation audits
- Perform other duties and special projects as assigned by QI Director, Director of Pharmacy, Quality and Health Management (PQHM) and Medical Director
- 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
- Bilingual in Mandarin and or Cantonese is preferred
- Able to lift up to 30 pounds
- Use proper body mechanics when handling equipment
- Standing, walking and moving 50% of the day.
Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, 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.