Quality Management Appeals and Grievances Intake Coordinator

University of California - Los Angeles Health
United States, California, Los Angeles
Feb 26, 2025
Description The Appeals & Grievance Intake Coordinator serves as the primary point of contact for receipt of member-initiated complaints and Health Plan grievances and appeals. The Grievance and Appeals Intake Coordinator is responsible for managing the grievances and appeals shared email inbox and fax portal of received complaints, appeals and grievances. The management of grievances includes initial intake and triage, independently determining priority, information needed, creation of the case in the medical records system, and appropriate assignment to G&A staff. This position will interface with internal and external resources and organizations in a professional manner to ensure that all complaints, appeals, and grievances are properly initiated and assigned. This position is responsible for the day-to-day functions of the tracking and trending of all Health Plan initiated grievances and appeals received within the Quality Management department. This position will act as the primary contact person for member and provider grievances and appeals. Key Responsibilities: Serves as the UCLA Medical Group initial point of contact for all internal complaint and health plan-initiated member appeals and grievances including initiation and assignment of cases applying NCQA, State and Federal regulations with direction from the Medical Director and QM Manager. Review all member appeals and grievances for accuracy, ensuring that proper documentation from the requestor is received, ensuring compliance and contractual obligations with state and federal regulations laws and regulations. Creates and tracks all complaints, grievances and appeals in the Care Connect CRM system in an accurate and timely manner. Interface with internal and external resources and organizations in a professional manner to ensure that all complaints, appeals, and grievances are properly initiated and assigned. Maintains well-organized, accurate and complete case files for all complaints, grievances and appeals. Responsible for file maintenance, including but not limited to filing and file purging, according to department protocol. Accurately documents grievances and appeals in the tracking system, compiles, and maintains statistical data consistent with department guidelines for presentation to the Medical Director and UM/QM Committees. Assists external and internal customers with any issues/questions relating to the complaint, grievance, and appeals process as well as other business support systems. Provides resolution to interested parties within established turnaround timeframes. Maintains communication with management on all issues that have been addressed. Consistently maintains quality standards in accordance with department policy. Completes data entry, documentation, and correspondence in a thorough, professional, and expedient manner as necessary for each review. Reviews all relevant reference materials that are provided including via e-mail and interoffice memo, and reviews updates made to pertinent policies and procedures. Performs special projects and other duties as assigned or requested by the Medical Director or Manager. Salary Range: $31.45 - $43.17 Hourly Qualifications High school diploma, GED or equivalent experience required Minimum of 3 years of managed care environment experience (i.e., MSO, IPA, or health plan) required Working knowledge of utilization review/referral processing systems (i.e., EPIC) Working knowledge of CPT-4, ICD-10, and HCPCS codes as well as thorough understanding of Medicare Guidelines, COB and TPL coordination Knowledge of benefit interpretation, referral/authorization processes, contracts, and flow of related information Demonstrated medical terminology competence Ability to assess problems, formulate plans, solutions, and a course of action Ability to work independently utilizing department established tools and guidelines Ability to multi-task, meet deadlines and maintain department production and quality standards Proficient computer skills including Microsoft Excel and Word. Familiarity with Microsoft Access a plus. Competence in navigating the internet Team orientation and ability to work effectively across functional areas of the company Strong interpersonal, verbal, and written communication skills. Ability to communicate well with internal and external customers, providing timely and accurate information as needed