Career Opportunities: Appeals & Grievance Coordinator I (24911)

Candidates hired for remote positions must reside in Oregon, Washington, Utah, Idaho, Arizona, Nevada, Texas, Montana, or Wisconsin.

Job Summary

The Appeals & Grievance Coordinator I position is responsible for coordinating appeals and/or grievances at the entry level. This includes tracking, documentation, collection and file maintenance, all in strict compliance with state and federal regulatory requirements. This role requests documentation as needed to review and process determinations in accordance with policies and procedures. Additionally, the position may communicate with members and other internal and external customers in matters relating to appeals and/or grievances. 

Essential Responsibilities

• Receive and validate requests for appeals and/or grievances.
• Review appeals and/or grievances to ensure compliance with state and federal requirements.
• Communicate with members and providers in accordance with state and federal requirements as needed to complete requests. 
• Locate or request necessary information from internal and external sources to complete appeals and/or grievance reviews.
• Cross-train on appeals, grievances, additional lines of business and other areas as needed.
• Maintain and track accurate and complete records and other documentation.
• Work with Quality Assurance clinicians, other CareOregon staff and delegated entities to ensure that appeals and/or grievance requests are managed in accordance with state and federal guidelines.
• Route appeals and/or grievance requests to the appropriate staff for additional review when needed.
• Create documents to share final resolution of appeal/grievance with members and/or providers.
• Prioritize and organize work to effectively meet strict deadlines as outlined by state and federal requirements; ask for assistance if uncertain of priorities.
• Responsible for consistently meeting high production and quality standards.
• Maintain confidentiality of all communications, records, and other data in accordance with HIPAA regulations, established quality management processes, and the highest professional standards.   
• Collaborate with teams across the Clinical Operations department to ensure work and goals are met. 
• Assist with gathering and assembling documentation and records needed for audits, external reviews, administrative hearings and internal committees.

Organizational Responsibilities

• Perform work in alignment with the organization’s mission, vision and values.
• Support the organization’s commitment to equity, diversity and inclusion by fostering a culture of open mindedness, cultural awareness, compassion and respect for all individuals.
• Strive to meet annual business goals in support of the organization’s strategic goals.
• Adhere to the organization’s policies, procedures and other relevant compliance needs.
• Perform other duties as needed.

Experience and/or Education

Required

• Minimum 1 year experience providing administrative support, customer service, clerical processing, and/or clerical production support

Preferred

• Experience with Appeals and Grievances, Claims or Utilization Management
• Experience working with Medicaid or Medicare
• Experience with insurance billing
• Experience in a medical, healthcare or insurance setting

Knowledge, Skills and Abilities Required

Knowledge

• Knowledge of medical and health insurance terminology preferred
• Knowledge of Medicaid health plan and Medicare benefits preferred
• Knowledge of applicable DMAP rules and regulations preferred
• Knowledge of managed care principles preferred

Skills and Abilities

• Ability to consistently meet high production standards
• Ability to consistently meet high quality standards
• Ability and willingness to cross-train as needed
• Ability to adhere to HIPAA regulations (e.g., maintain confidentiality of protected health information) 
• Computer skills including ability to use Microsoft Office applications and internet search functions
• Ability to proofread work and ensure accuracy 
• Ability to work in fast-paced environment with tight deadlines and high-quality standards
• Ability to independently prioritize work  
• Growing ability to use critical thinking and problem-solving skills 
• Excellent spoken and written communication skills, including correct spelling and grammar
• Good customer service skills 
• Ability to work with internal and external persons to effectively resolve cases
• Growing ability to respond to sensitive or complex issues with tact and diplomacy
• Good interpersonal skills and ability to work cohesively within a team environment

• Ability to work effectively with diverse individuals and groups

• Ability to learn, focus, understand, and evaluate information and determine appropriate actions
• Ability to accept direction and feedback, as well as tolerate and manage stress
• Ability to see, read, and perform repetitive finger and wrist movement for at least 6 hours/day
• Ability to hear and speak clearly for at least 3-6 hours/day

Working Conditions

Work Environment(s):  ☒ Indoor/Office    ☐ Community      ☐ Facilities/Security     ☐ Outdoor Exposure

Member/Patient Facing:    ☐ No                          ☒ Telephonic        ☐ In Person

Hazards:  May include, but not limited to, physical and ergonomic hazards.

Equipment:  General office equipment

Travel:  May include occasional required or optional travel outside of the workplace; the employee’s personal vehicle, local transit or other means of transportation may be used.

#MULTI

Candidates of color are strongly encouraged to apply. CareOregon is committed to building a linguistically and culturally diverse and inclusive work environment.

Veterans are strongly encouraged to apply.

We are an equal opportunity employer. CareOregon considers all candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, or veteran status.

Visa sponsorship is not available at this time.