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Senior Grievance Appeals Coordinator
Ref No.: 18-16384
Location: Scottsdale, Arizona
Description:
Job Description Summary
Performs research and analysis of grievances filed by members, to administer timely resolution within state and federal guidelines, benefit plan guidelines, and company policies and procedures. Maintains a caseload of grievances and performs assigned duties.
Job Description
ESSENTIAL FUNCTIONS:
- Outreach contact and written notification with members with resolution to Grievance.
- Consults with internal departments such as Clinical, and Network, as well as company senior management to assure Grievances and complaint decisions meet all guidelines and result in customer satisfaction when possible.
- Consults with Account Management and external vendors to resolve high profile, complex appeals and/or complaints.
- Responsible for preparation of written detailed case history.
- Documents process and findings within the Grievance and internal systems.
- Responsible for interface with members and providers as required regarding status, process and outcomes of complaints and appeals.
- Responsible for maintaining the integrity of the company relationship with customers by researching, resolving and responding to customer inquiries for disputes.
- Responsible for identifying risk situations, consulting with senior management staff and rendering determinations that could adversely affect the company.
- Researches, compiles and consults with external review organization and customers as necessary.
- Assists in data gathering and reporting of Grievances.
- Responsible for achieving and maintaining department performance guarantees.
- Assists in developing workflows and innovative process improvements to positively impact the department overall.
- Contributes to unit and department CQI (continuous quality improvement) processes by participating in unit goal setting, scorecard development and departmental meetings. Meets individual performance standards.
- Other duties as assigned.

Requirements/Certifications:
Must have: Med D background
Duration: Temporary only through end of March 2019
Hours: Mon-Fri, Flexible between 8:30a-5p
Education: HS or GED