• Grievance and Appeals Coordinator

    Job Locations US-VA-Glen Allen
    Job ID
    2018-4734
  • Overview

    The Grievances and Appeals Coordinator core function is to inform and educate plan members and practitioners on the process to properly submit a formal grievance and/or appeal.  Additionally will manage, investigate and resolve member and practitioner grievances/appeals, to include appeals related to medication, medical, or service denials in accordance with Virginia Premier Health Plan’s (VPHP) policies and procedures as well as regulatory and accreditation requirements. The Grievances & Appeals Coordinator shall also be responsible for serving as the plan’s expert and liaison for the members and practitioners related to all grievance and appeals activities.

    Responsibilities

    • Responds to member and practitioner grievances/appeals with minimal direction; while assisting members, via phone or face to face, further supports quality related goals.
    • Investigates and resolves member and practitioner grievances/appeals within plan, regulatory and accreditation time-frames
    • Prepares, attends and presents grievances/appeals documentation for plan, regulatory hearings and/or during audits, as needed
    • Documents all grievances/appeals in an accurate and timely manner per policy, related follow-up activities and final outcomes in designated systems while concurrently maintaining secure, comprehensive and clearly defined files
    • Provides timely assistance to members and practitioners in filing a formal grievance/ appeal and ensures that members and practitioners are advised of their appeal rights
    • Works collaboratively, coordinates, communicates and integrates recommendations from impacted organizational departments, senior Level Executives and other designated staff
    • Generates reports with trend analysis and recommendations for quality improvement to Manager
    • Communicates detailed account of risk management issues to the Manager within the specified time-frame
    • Assists with training, in-services and quality audits as a result of plan, regulatory or accreditation requirements
    • Attend Member Advisory Committee (MAC) and Provider Advisory Committee (PAC) meetings, as needed

    Qualifications

    MINIMUM EDUCATION REQUIREMENTS

    • Bachelor degree in a health care related field or LPN preferred.

     SPECIAL KNOWLEDGE AND/OR SKILLS

    • Strong written and oral communication skills
    • Bilingual communication skills required (Spanish speaking preferred)
    • Exceptional interpersonal and problem solving skills
    • Positive and approachable demeanor
    • Flexible (Outside of the Box) Thinker
    • Must be able to multi-task
    • Working knowledge of the Grievances/Appeals Processes and related legislation
    • Knowledge of medical terminology
    • Knowledge of the managed care industry
    • Demonstrated experience in quality project management from start to finish to include, but not limited to receiving a request, data/document finding, ensuring proper and timely assessment of data by the appropriate staff, resolution and follow-up, as required
    • Computer experience with Microsoft office software including Access and Excel 


    WORK BACKGROUND/EXPERIENCE

    • Minimum of 1 year of experience applying accreditation and regulatory requirements and ensuring ongoing compliance
    • Customer service experience in a medical environment
    • Knowledge of Medicare and Medicaid
    • Ability to succinctly deliver information to a variety of audiences to include members, practitioners, organizational executives, attorneys and/or accreditation and regulatory auditors
    • Proficiency with computers and word processing programs
    • Experience working with low income, indigent and/or disadvantaged populations

     

    ELIGIBILITY REQUIREMENTS

    • Willing and able to confirm to a pre-employment background check.
    • Willing and able to accommodate minimal travel as needed.
    • Must be willing and able to provide on-call weekend coverage on a once-per-month rotating schedule
    • Must be willing and able to provide coverage up to 6 p.m. one day per week.

    PHYSICAL REQUIREMENTS

    • Physical health sufficient to meet the ergonomic standards and demands of the position

    About Us

    Virginia Premier is a managed care organization which began as a full-service Medicaid MCO in 1995. Partnered with VCU Medical Systems we strive to meet the needs of the underserved and vulnerable populations in Virginia by delivering quality driven, culturally sensitive and financially viable Medicare and Medicaid healthcare programs.  Headquartered in Richmond, VA we also have offices in Roanoke, Tidewater and Bristol with additional satellite locations allowing us to serve over 200,000 members across eighty counties throughout Virginia. 

     

    We offer competitive salaries and a comprehensive benefits package to include excellent Medical, Dental and Vision Plans, Tuition Assistance, Infant-At-Work Program, Remote Work options and generous vacation and sick leave policies. Our culture supports an environment where employees can continuously learn and gain professional growth through various development programs, education, exciting projects and career mobility.  

     

    Our mission is to inspire healthy living within the communities we serve!

     

    Equal Opportunity Employer All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

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