Customer Solution Center Appeals and Grievances Coordinator I

Job Summary

The Customer Solution Center Appeals and Grievances Coordinator I supports the Customer Solution Center Appeals & Grievance Specialists by handling the administrative functions of the care management/continuity of care process including intake, logging, tracking and status follow-up.

This position collects information required by clinical staff to render decisions, assists the Customer Solution Center Appeals & Grievance Manager and Director in meeting regulatory timelines by maintaining an accurate database inventory of care management and continuity of care cases, and preparing monthly activity reports.

In addition, the position performs data entry and processing of health risk assessments in the system, maintains confidentiality when communicating member information, and assists with the communication and coordination between programs. Prepares template determination/education letters for members and providers.

Duties

Provide non-clinical support to the Customer Solution Center Appeals and Grievance Specialists for L. A. Care's Medicare Advantage program. This includes the technical aspects of the time sensitive processes for initiating cases, managing referral documentation, entering  pre-certification/continued authorizations, identifying and  responding to urgency of  the request, appropriate documentation, case routing & tracking, routing of  information, performing computer data input, faxing, filing of  confidential member information, and maintaining logs of activity, etc.).  (40%)

Assist in the telephonic outreach calls to members identified during health risk assessments as in needed of care coordination assistance. Consist of follow up calls to members to administer screening or obtaining clarification on initial responses.  (25%)

Under the supervision of the Appeals and Grievance Manager, assist with soliciting non-clinical information from Participating Physical Group (PPG) and specialist concerning follow care related to care management. (15%)

Maintain the monthly reporting responsibilities, Appeals and Grievance reporting to Department Director, ongoing referrals and authorizations  for members in complex care management. (5%)

Accurately maintain an updated log of L.A. Care  members identified as SPD or eligible with CCS cases. If members become ineligible with L.A Care or a specific program  members are referred to Member Services for transition to other applicable  programs".  (5%)

Perform other duties as assigned. (10%)

Duties Continued

Education Required

Education Preferred

Experience

Required:
At least 0-6 months of experience in Medi-Cal managed care authorization processes and/or as a Medical Assistant.

Skills

Required:
Knowledge of medical terminology and ICD-10 and CPT codes. 

Strong verbal and written communication skills.

Proficiency with Microsoft Word, Excel, and Access.

Excellent organizational, interpersonal and time management skills. 

Must be detail-oriented and an enthusiastic team player. 

Knowledge of MHC computer system a plus.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information