New job Medical Grievance and Appeals Coordinator; San Francisco Bay Area!

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Group: Job Openings, Job Leads and Job Connections! Subject: Medical Grievance and Appeals Coordinator; San Francisco Bay Area! April Starlight posted a job: Medical Grievance and Appeals Coordinator; San Francisco Bay Area! "Responsibilities: PRINCIPAL RESPONSIBILITIES INCLUDE: Grievances and Appeals: • Ensure compliance with state and federal regulations as they relate to appeal and grievance issues. • Serve as the liaison with other departments to resolve grievance issues. • Maintain an accurate and complete appeals/grievance record in the electronic database. • Coordinate the Alliance component of the State Fair Hearing, MAXIMUS and HSAG appeal submission, Medicare Administrative Law Judge Hearing, Independent Medical Review (IMR), and DMHC appeal processes. Potential Quality Issues: • Coordinate the Alliance processes to identify, analyze, and resolve potential quality of care and service issues (PQI). • Work with the Medical Director(s), the Quality Improvement Nurses, and other departments to ensure the timely processing of PQI. • Notify the Medical Director(s) immediately about PQI events that are adverse, high risk, or may result in a delay of medically necessary care. • Review PQI documents for accuracy and completeness. General: • Monitor program performance to maintain compliance with federal and state regulatory agencies: DHS, MRMIB, DMHC, and CMS. • Ensure timely communication with the Manager on all/any issues having potential risk and or impact on operations. • Handle escalated member and provider concerns with the dual goal of ensuring satisfaction and retention. • Make decisions within department guidelines and policies • Maintain quality management documents, case files, and correspondence in an organized, confidential, and secure manner. • Maintain databases for tracking and reporting purposes. • Prepare complete and accurate reports and presentations on grievances and appeals, delegated audit results, and PQI resolution. • Complete other duties as assigned. ESSENTIAL FUNCTIONS OF THE JOB: • Participate in delegated audit activities. • Coordinate grievance and appeal activities. • Coordinate PQI activities. • Perform writing, administration, analysis, and report preparation. PHYSICAL REQUIREMENTS: • Constant and close visual work at desk or computer. • Constant sitting and working at desk. • Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person. • Frequent lifting of folders, files, binders and other objects weighing between 0 and 30 lbs. • Frequent walking and standing. • Frequent driving of an automobile. • Frequent travel between offices for meetings. • Possible travel by aircraft. Qualifications: MINIMUM QUALIFICATIONS: EDUCATION OR TRAINING EQUIVALENT TO: • Bachelor's degree in Health Services or related field or equivalent experience. MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE: • Minimum three years experience in managed care, hospital, or similar setting. SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): • Knowledge of NCQA, Title 22, Title 10, and other regulations governing provider participation in managed care. • Experience in quality and utilization management systems. • Proficient experience in Microsoft Word, Excel, Access, Outlook, and PowerPoint. • Excellent verbal and written communication skills a must. This role is contract to hire, to apply or find out more information, contact astarlight@ascentsg.com or call 925-627-4956!"

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