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Grievance and Appeals Coordinator

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Centers Plan for Healthy Living is seeking a Grievance and Appeals Coordinator

Centers Plan for Healthy Living (CPHL), is a Managed Care Organization servicing members with Medicare and/or Medicaid.  Our goal is to provide members and all those involved in their care with the guidance and health plan choices they need for healthy living. CPHL is committed to providing quality, coordinated health care to some of the most honored and yet still vulnerable members of our community 

JOB SUMMARY

As an integral part of the Grievance and Appeals (G&A) Department, the G&A Coordinator lends their support in processing member-related grievances and appeals across CPHL’s various lines of business. Process includes gathering, documenting, tracking, and pursuing resolution of complaints in accordance with regulatory and organizational guidelines to the member’s satisfaction.

PRIMARY RESPONSIBILITIES    

  • Logs and tracks verbal or written member grievances and appeals.
  • Conducts relevant research into complaints and collaborates, coordinates and communicates with various departments (i.e. Member Services, Care Management, Claims), as well as external entities (i.e. Providers and Vendors) to collect additional information as necessary.
  • Maintains a current knowledge of plan products, policies and procedures with the ability to relate acquired knowledge in a clear, concise and understandable manner to members, providers, and internal staff. 
  • Ensures grievances and appeals are handled and resolved in compliance with timeliness requirements, and at the highest standards for accuracy.
  • Prepares, generates, and mails letters, forms, and other G&A-related notices.
  • Maintains confidentiality of all protected health information in accordance with state, federal, and corporate guidelines.
  • Performs other duties as assigned

REQUIREMENTS

High school diploma or equivalent required. Associate’s Degree preferred
Minimum two years of experience in customer service or health service environment. Previous experience in Managed Care grievances/appeals preferred. Strong communication, organizational, critical thinking, and problem solving skills.       

We are an Equal Opportunity Employer –M/F/D/V

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