BusinessOperations - Grievance & Appeals Coordinator I - 210056

BusinessOperations

• Grievance & Appeals Coordinator I
• 210056#26-06339 $23 per hour Woodland Hills, CA

All On-site Job Description Position Purpose:

Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members.

Education/Experience:

High school diploma or equivalent. Associate's degree preferred. 2+ years grievance or appeals, claims or related managed care experience. Strong oral, written, and problem solving skills.

• Gather, analyze and report verbal and written member and provider complaints, grievances and appeals
• Prepare response letters for member and provider complaints, grievances and appeals
• Maintain files on individual appeals and grievances
• May coordinate the Grievance and Appeals Committee
• Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information
• Assist with HEDIS production functions including data entry, calls to provider's offices, and claims research.
• Manage large volumes of documents including copying, faxing and scanning incoming mail

EEO:

"Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of

• Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.

" ============== Story Behind the Need What is the purpose of this team? Describe the surrounding team (team culture, work environment, etc.) & key projects. Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative? We are seeking a Coordinator for Health Net Appeals and Grievances to join our dynamic team. This role is essential to supporting our team's high standards ensuring quality measures meet or exceed 97%. The coordinator will collaborate with the team on cases, contributing to continuous improvement initiatives and enhancing customer experiences. We foster a supportive, collaborative culture focused on customer care, curiosity, and operational efficiency. This role offers growth potential within a team dedicated to excellence and business success. We are always hiring. Typical Day in the Role Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD). What are performance expectations/metrics? What makes this role unique? A typical day in the role of a Case Coordinator for Appeals and Grievances involves processing and resolving member appeals and grievances, ensuring each case is handled with accuracy and timeliness. The coordinator collaborates closely with the member and team on cases, providing essential support and maintaining clear communication throughout the process. The role also involves contributing to continuous improvement initiatives, identifying opportunities to enhance operational efficiency and customer satisfaction. Daily tasks require a keen attention to detail, effective problem-solving, and teamwork within a supportive and collaborative environment. The coordinator will be required to work Monday through Friday 8am to 5pm with overtime as need and occasional Saturdays/holidays. his Case Coordinator role in Appeals and Grievances is uniquely rewarding, offering the opportunity to make a meaningful impact on member experiences while working within a supportive and collaborative team culture. Our team is dedicated to continuous improvement, encouraging curiosity, problem-solving, and personal growth. The role provides exposure to complex cases, enhancing analytical and communication skills, and offers the chance to work closely with cross-functional teams. Joining us means being part of a dynamic environment that values customer care, operational excellence, and professional development, making it an ideal role for those seeking both challenge and growth. Applications

• word, excel, teams, outlook, onedrive, one note Centene applications
• Prime, omni Candidate Requirements Education/Certification

Required:

i.e. High School diploma

Preferred:

Licensure

Required:

N/A

Preferred:

Must haves:

• 2-3 years of experience in a similar role, within appeals and grievances, healthcare administration, or customer service in a regulated environment.
• Experience working with complex cases or compliance-related tasks is highly desirable. Nice to haves:
• Knowledge of Healthcare Regulations
• Understanding of health plan compliance, regulatory requirements, or experience with Medicare/Medicaid guidelines.
• Conflict Resolution Skills
• Ability to handle sensitive cases with professionalism and empathy.
• Project Coordination Experience
• Exposure to coordinating cross-functional projects or initiatives in a fast-paced environment.
• Good Letter writing skills

Disqualifiers:

• Lack of Experience in Appeals/Grievances OR healthcare Environments
• Candidates without relevant experience in healthcare, insurance, or similar regulatory fields may not be suitable.
• Poor Attention to Detail
• Inaccuracies or errors in case handling can impact quality standards.
• Inadequate Communication Skills
• The role requires clear and effective communication with team members and stakeholders.
• Lack of Problem-Solving Skills
• Inability to contribute to continuous improvement or resolve complex cases collaboratively. Performance indicators:
• Accuracy and Quality Compliance
• Consistently meets or exceeds the 97% quality standard with minimal errors.
• Efficiency and Productivity
• Completes case reviews and resolutions ahead of deadlines while maintaining high standards.
• Effective Collaboration and Communication
• Proactively collaborates with the management team and cross-functional departments, contributing to positive team dynamics and problem-solving.
• Customer Satisfaction and Resolution
• Resolves member grievances effectively, contributing to high customer satisfaction ratings.

Top 3 must-have hard skills stack-ranked by importance 1 Attention to detail and accuracy 2 Strong communication and collaboration 3 Analytical and problem-solving skills/ tech savvy