Senior Grievance and Appeals Coordinator

OPEN ONLY TO THOSE WHO RESIDE IN ARIZONACORE FUNCTIONS:

• Maintains State Fair Hearing Logs with appropriate information required by HP policy, AHCCCS, HCG, and CMS regulations.
• 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.
• 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.
• Assists with project management of departmental improvements. Coordinates with other departments on Grievance & Appeals projects/work groups.
• Assists the Marketing Department with the production of all member letters and notices. Participates actively in meetings, work groups, 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.
• 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.
• 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.
• 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.
• 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.

• 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
• 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.