UPMC Health Plan has an exciting opportunity for a Member Complaints & Grievances Coordinator I position in the Member CGA department. This is a full time position working Monday through Friday daylight hours. This is a remote position.
The Member C & G Coordinator will track, trend, and manage member grievances, appeals, and IRE requests for the Medicare and SNP product lines. Ensure the efficient and effective resolution of member grievances, appeals, and IRE requests according to department and regulatory timeframes. Compose professionally written letters for members and employ the use of all Medicare and SNP processes and meet timeliness guidelines. Manage multiple case types simultaneously. Adhere to CMS guidance and comply with all regulatory timeframes. Use the data collection and analysis to target initiatives for opportunities for improvement within the Health Plan. Meet Medicare and SNP guidelines for quality and production.
Candidates must be legally authorized to work in the United States, without requiring, now or in the future, sponsorship for employment visa status. UPMC does not participate in STEM OPT.
Responsibilities:
- Investigate member complaints and grievances, and provider appeals, and respond in writing according to department standards.
- Effectively utilize key internal and external Health Plan contacts, including Health Plan staff, providers, and external review organizations, to help in this process.
- Organize all tasks within regulatory requirements/deadlines.
- Ensure member and provider concerns are thoroughly and accurately addressed according to regulatory guidelines.
- Understand and interpret medical information, recognize trends, and identify opportunities for improvement within the Health Plan.
- Prepare Independent Review Entity case files dependent online of Business.
- Assist in reporting complaint and grievance data to appropriate regulatory bodies and internal departments.
- Maintain quality and performance metrics as outlined by Supervisor.
- Constructs IRE Packets as needed.
- Associate degree or equivalent professional work experience.
- 1 year of experience in a health care environment required.
- Medical claims and/or customer service background preferred.
- Demonstrated success problem solving and decision making with a solid understanding of managed care principles.
- Excellent verbal and written presentation skills are essential.
- PC literacy with proficiency in the use of Microsoft office products.
- Familiarity with ICD-10, HCPCS, and CPT4 coding and medical terminology.
- Experience with Medicare and SNP preferred.
Licensure, Certifications, and Clearances:
UPMC is an Equal Opportunity Employer/Disability/Veteran