Appeals & Grievances Coordinator - Remote

About the Role

The day-to-day responsibilities of this role will involve tracking and trending grievances and appeals, conducting investigations, and communicating with members and providers to resolve issues. The coordinator will also be responsible for maintaining accurate and timely documentation, preparing reports, and participating in periodic reviews and updates of policies and procedures.

Alignment Health is committed to serving seniors and the chronically ill, and this role is a critical part of that mission. The company is looking for a skilled and compassionate coordinator who can provide exceptional service to its members and providers.

What You Will Do

• Acknowledge receipt of all grievances and appeals and track them in the Complaint Tracking Module
• Gather pertinent and relevant information from members and providers regarding grievances and appeals
• Determine the appropriate resolution of grievances and appeals per standard policies and procedures
• Notify the appropriate parties of the resolution and ensure that all internal processes are completed to resolve the issue
• Compose written correspondence to members in accordance with plan policy and CMS Guidelines
• Conduct non-biased, accurate, timely, and comprehensive investigations of all facts related to grievances and appeals
• Thoroughly document all action taken on behalf of members or providers to resolve grievances and appeals
• Ensure that all grievances and appeals are processed in adherence to CMS guidelines and plan policy
• Prepare case files for Medical Director Review and external review of grievances and appeals as appropriate
• Prepare clear, objective, accurate, and comprehensive case histories for presentation and consideration at committee meetings
• Maintain accurate and timely documentation, including complete files of all grievances and appeals
• Prepare monthly and quarterly reports as requested

What We Are Looking For

• Two years of experience in data entry and general office background
• Three years of customer service experience
• Minimum one year of Member Services or similar experience
• High School Diploma or GED
• Ability to keyboard/type 40+ words per minute and use the 10-key by touch
• Ability to communicate positively, professionally, and effectively with others
• Effective written and oral communication skills
• Ability to establish and maintain a constructive relationship with diverse members, management, employees, and vendors

Nice to Have

• Two years of healthcare or insurance experience in a senior setting
• Associate degree (A.A.)
• Knowledge of MediCal and Medicare Managed Care Plans

Benefits and Perks

• Competitive salary
• Comprehensive benefits package
• Opportunity to work with a dynamic and growing company
• Remote work arrangement
• Professional development opportunities
• Recognition and reward for outstanding performance

• Be prepared to provide specific examples of your experience in grievance resolution and customer service
• Familiarize yourself with the company's mission and values, and be ready to explain how your skills and experience align with them
• Make sure your resume and cover letter are tailored to the job description and highlight your relevant skills and experience
• Practice your communication skills, as effective written and oral communication is critical in this role
• Be prepared to ask questions during the interview, such as what a typical day looks like in this position or what opportunities there are for professional development