CTM Coordinator, Appeals & Grievances - Remote work weekends

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve.

In this fast‑growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

This position is a remote position. Candidates must be willing to work weekends.

• Monitors the CTM portal daily for new cases.
• Acknowledges receipt of all Complaint Tracking Module (CTM) grievances and appeals cases.
• Gathers pertinent information from members, providers, internal departments and delegated entities to determine the appropriate resolution in accordance with standard policies and procedures, notifies the appropriate parties, and ensures completion of all internal processes required to resolve the issue ahead of regulatory deadlines.
• Completes outreach (verbal and written correspondence) to members and providers in accordance with plan policy and Centers for Medicare & Medicaid Services (CMS) guidelines.
• Conducts unbiased, accurate, timely, and comprehensive investigations of all facts related to CTMs cases, as well as grievances and appeals.
• Thoroughly documents all actions taken to resolve cases in accordance with CMS regulatory time frames and internal policy and procedure.
• Tracks all cases to closure, ensuring timely and comprehensive documentation that satisfies CMS regulatory requirements.
• Ensures all CTM cases; grievances and appeals are processed in accordance with CMS guidelines and plan policy.
• Drafts clear, compliant written responses to CMS within required turnaround times.
• Prepares clear, objective, accurate, and comprehensive case histories for presentation and consideration at committee meetings and work groups.
• Prepare monthly and quarterly reports as requested.
• Assists in preparing reporting for compliance needs and regulatory audits.
• Identifies appeal, grievance and complaint trends, systemic issues and opportunities to improve member experience and reduce complaint volume.
• Contributes suggestions that support strong CMS STAR performance.
• Participate in periodic reviews and updates of CTM, grievance and appeal policies and procedures to reflect applicable legal and CMS requirements.
• Participates in CMS audit preparation and regulator meetings and interviews.
• Meets or exceeds all internal and regulatory deadlines.
• Performs other duties as assigned.

• Experience
  
  Required:
  
  At least one year of Member Services or similar experience.
• 2+ years of experience working with Medicare Advantage healthcare plans.
• Preferred:
  Direct experience working with CTM cases at a Medicare Advantage healthcare plan.

• High school diploma or GED.
• Preferred:
  Associate degree (A.A.).

• Strong oral and written communication skills.
• Ability to draft CMS facing correspondence.
• High attention to detail with ability to manage multiple deadlines driven cases simultaneously.
• Ability to type at least 40 words per minute and use a 10-key keypad by touch.
• Ability to communicate positively, professionally, and effectively; demonstrate leadership; teach; and collaborate across departments.
• Ability to establish and maintain constructive relationships with diverse members, management, employees, and vendors.
• Ability to read and interpret safety rules, operating and maintenance instructions, and procedure…