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Grv/Appeals Associate - (27379-1 MTPK)
Monterey Park, California | Contract
Wollborg Michelson is supporting a large healthcare organization in Monterey Park and we are currently seeking four Grievance and Appeals Associates. Associate will research and resolve member/subscriber grievances, appeals and complaints, and interpret and explain health plan benefits, policies and procedures to respondents. Researches, reviews and resolves high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process. Interprets and explains health plan benefits, policies, procedures and functions to members and providers. Produces complex written correspondence to resolve member grievances, appeals and complaints. Administers ongoing grievance tracking, trending and reporting for assigned grievances. Evaluates all grievances for trend purposes and reports periodic and ad hoc trends to Risk and Quality Management departments. Coordinates next level grievance/appeal meeting with appropriate parties and forwards documentation to the review committee. Establishes and maintains cohesive relationships with assigned IPA partners through telephone, field work and written communication.
In training (or recently completed), not consistently reaching production/quality standards
Identifies issues, and with assistance, executes corrective action Intake Queue. Complaint files Process QOC files. EID -Expedited Initial Determinations Performs established performance metrics
In the process of developing specific skills needed to perform non-routine tasks General knowledge of applicable legislation/regulations and actively maintains compliance
Minimum Experience Level
Typically 0-1 year of related experience