Grievance and Appeals Coordinator

Health Net, Inc. is a publicly traded managed care organization that delivers managed health care services through health plans and government-sponsored managed care plans. Its mission is to help people be healthy, secure and comfortable.

The Grievances and Appeals Coordinator will receive, investigate and resolve member complaints, member appeals, and provider disputes. The position will provide resolution of the grievance situations in compliance with legal and regulatory requirements

- Demonstrates regular, reliable and predictable attendance. - Collects, organizes and tracks information to facilitate and expedite processing of appeals received from a variety of sources. - Researches, investigates and resolves administrative aspects of the appeal, in compliance with corporate and governing regulations. - Prepares case files on member and provider appeals for internal or external review. - Processes, researches, and resolves provider disputes as assigned. - Documents the results of complaints and appeals and dispositions at all levels, including notification to providers and members. - Generates acknowledgement letters for complaints, appeals and provider disputes. Also generates resolution letters and medical records requests. - Assists with DMHC, URAC and Health Plan audit preparation. - Performs other related duties as assigned.

**Education:** High School diploma required **Certification/Licensure Required:** N/A **Government Clearance & US Citizenship Requirement:** N/A **Experience Required** - Minimum two years related experience to include customer service in a managed care environment, medical office or health insurance - Prefer experience in behavioral health claims processing. - Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position. **Knowledge, Skills & Abilities** - Working knowledge of regulatory and accreditation requirements - Understanding of appeals process and utilization management - Ability to formulate and write reports and professional correspondence - Strong organizational skills - Excellent oral and written communications skills with strong analytical and problem solving skills - Able to operate PC-based software programs - Proficiency in interpretation and application of service/legal contracts required - Knowledge of standard claims forms and coding used for physicians/billings, ability to read/interpret contracts, and knowledge of standard reference publications (RVS, CPT, ICD-9, and complete product and benefit coordination knowledge (COB, TPL, WC) **Working Conditions** - The following section describes the general physical requirements for this position. Please note that constant refers to more than 81% of time; significant refers to 40-80%; and moderate refers to 20-40% of the time. - Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment. - Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations. - May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays). - May be required to maintain established work pace, meet deadlines; may have last minute urgent requests. - Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc. - Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned. - Required to have hearing ability to receive detailed information through oral communication. - Required to have speaking ability to express or exchange ideas. - Constant concentration may be required on various subjects by listening, reading and thinking clearly. - Constant interaction with others may be required. May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required. This may require face-to-face or telephone interactions. - Constant thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next. - Significant computer usage including typing and/or eye strain. - Moderate repetitive arm, wrist, hand and finger motions - making repetitive movements (e.g. key boarding, filing, data entry). - Moderate phone usage; headsets may be required. - Moderate sedentary work (desk bound or seated). - Significant reading is required via computer screen and/or bound printed materials.