Senior Grievance and Appeals Coordinator

Job Description

**OPEN ONLY TO THOSE WHO RESIDE IN ARIZONA**

CORE FUNCTIONS:

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1. Maintains State Fair Hearing Logs with appropriate information required by HP policy, AHCCCS, HCG, and CMS regulations.
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2. Reviews all State Fair Hearing requests by members and providers, pulls case files, meets with Grievance & Appeals Manager for further review and action, which may include collaboration with others to avoid/reduce grievances, appeals, and/or claim disputes. May attend State Fair Hearings.
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3. Coordinates and assists the Grievance & Appeals Manager in preparing for higher levels of appeals (i.e., Independent Review Entity reviews, hearings, etc.), including telephonic requests.
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4. Assists with project management of departmental improvements. Coordinates with other departments on Grievance & Appeals projects/workgroups.
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5. Assists the Marketing Department with the production of all member letters and notices. Participates actively in meetings, workgroups, and committees relevant to the Grievance & Appeals process. May produce, prepare, quality check, or deliver all reporting requirements in the absence of the Grievance & Appeals Manager.
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6. Produces and analyzes weekly and monthly data to determine trends and provides recommendations for intervention. Assists with internal, external, and self-audits of the department and annual data validation.
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7. Produces a Monthly Operational Dashboard. Produces, analyzes, and reports monthly data to ensure regulatory compliance. Updates Grievance & Appeals data in conjunction with the Marketing department on all HP websites.
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8. Monitors and resolves member and provider expedited appeals and grievances received after hours and/or holidays when assigned to rotational on-call duty. Coordinate appropriate action by supporting clinical staff for processing of member and provider expedited appeals and/or grievances.
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9. This position works under supervision, prioritizing data from multiple sources to provide quality care and support. Incumbents work in a fast-paced, sometimes stressful environment with a strong focus on customer service. Interacts with staff at all levels throughout the organization.
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MINIMUM QUALIFICATIONS:

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• High school diploma/GED or equivalent working knowledge. Two years of work experience in a health care related field or experience managing projects/initiatives, or an equivalent combination of education and experience
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• Three to four years of grievance and appeal work in a health care environment, or an equivalent combination of education and experience. Maintains knowledge of AHCCCS, HCG, and CMS regulations by participating in training, teleconferences, and services.
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