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Grievance and Appeals Case Analyst

Company: Partnership HealthPlan of California
Location: Redding
Posted on: January 12, 2022

Job Description:

Overview:Represents PHC in the Grievance & Appeals Resolution process. Responsible for reviewing,
investigating, and resolving assigned member grievance and appeal cases ranging from low to
high complexity. Works to transform member dissatisfaction into member satisfaction. Oversees
the investigative process ensuring casework complies with DHCS guidelines, NCQA standards,
and PHC best practices. Works independently, provides leadership on each investigation,
prioritizes case deliverables, remains customer-focused, and stays current on changes in the
healthcare system that may trigger member dissatisfaction.Responsibilities:

  • Independently determines best resolution on assigned cases, incorporating clinical guidance
    from PHC Medical Directors and Grievance & Appeal Nurse Specialists.
  • Investigates member-disputes of denied benefits/services, collects new evidence, reassesses
    for coverage, executes final decisions, and communicates it to all stakeholders.
  • Investigates member-reported concerns about dissatisfactory experiences while seeking care.
    Identifies facts, surveys the health care system, corrects root causes, and communicates
    outcomes to all stakeholders.
  • Communicates with members throughout the investigation, offers customer-focused
    solutions, and practices exemplary customer service to all stakeholders. Frequent contact
    with internal departments, providers, third party administrators, and/or regulators.
  • Manages assigned cases so they are completed within DHCS timeframes, according to G&A
    Desktop procedures, and/or as directed by management.
  • Documents all casework activity thoroughly, accurately, timely, and ethically.
  • Writes DHCS and NCQA compliant letters to members and providers.
  • Provides leadership to the grievance support team to complete sub-components of the
    investigation process.
  • Effective communicator in all modes of communication (e.g., written, verbal).
  • Knows all PHC Medi-Cal benefits or has the ability to master understanding of all benefits.
    Maintains knowledge of PHC Medi-Cal Handbook, PHC Policy & Procedures, and DHCS
    guidelines affecting benefits.
  • Identifies systematic or recurring issues that create barriers to high quality healthcare and
    reports them to leadership.
  • May serve as backup to absent Grievance & Appeals Case Analyst(s).
  • Attends meetings as needed including but not limited to Case Conferences, Case Forum
    Meetings, Department Meetings, and Division Meetings.
  • Other duties as assigned.Qualifications:Education and Experience
    Bachelor's degree or four (4) years of related work experience, preferably in
    Grievances & Appeals, health care customer service, case management or
    health plan operations.
    Special Skills, Licenses and Certifications
    Ability to solve problems, be a critical thinker and detail oriented. Familiar
    with managed care concepts, operations, policies and procedures, including
    but not limited to knowledge of grievance and appeal regulations. Strong
    knowledge of Microsoft Word, Excel, and Outlook. Bilingual skills in
    Spanish, Tagalog, or Russian preferred, but not required. Valid California
    driver's license and proof of current automobile insurance compliant with
    PHC policy are required to operate a vehicle and travel for company
    Performance Based Competencies
    Excellent oral and written communication skills. Ability to exercise discretion
    and independent judgment. Must be able to handle multiple tasks and meet
    deadlines. Strong organizational skills with ability to prioritize work. Must be
    able to work in a fast-paced environment, work well under pressure, and
    maintain professional composure when interacting with all stakeholders,
    including members.
    Work Environment And Physical Demands
    Daily use of telephone and computer. More than 70% of work time is spent in
    front of a computer monitor. Standard cubical workstation. When required,
    ability to move carry or lift objects weighing up to 25 lbs.
    All HealthPlan employees are expected to:

    • Provide the highest possible level of service to clients;
    • Promote teamwork and cooperative effort among employees;
    • Maintain safe practices; and
    • Abide by the HealthPlan's policies and procedures, as they may from time to time be
      The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

Keywords: Partnership HealthPlan of California, Redding , Grievance and Appeals Case Analyst, Professions , Redding, California

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