General Description

Implement HPSM’s Grievance and Appeals processes by resolving complaints filed by HPSM members and their representatives as well as provide back-up support to Member Services and CareAdvantage units.

Duties & Responsibilities

Essential Functions:

• Research and resolve member complaints for all lines of business ensuring compliance with HPSM’s Grievance and Appeals policies and procedures.
• Maintain grievance and appeals case files in HPSM’s database.
• Effectively communicate with members and providers verbally and in writing.
• Prepare summaries and write resolution letters for members, which include summarizing member complaints and steps taken to resolve complaints in clear and grammatically correct language.
• Attend and present cases at bi-weekly Staff Grievance and Appeals Committee.
• Prepare files for appeals to regulatory agencies.
• Maintain current on all regulatory requirements as they apply to grievance and appeal processes.
• May, as needed, provide necessary coverage in the call centers for Member Services and CareAdvantage.

Secondary Functions:

• Perform other duties as assigned.

Qualifications  

The following represents the typical way to achieve the necessary skills, knowledge and ability to qualify for this position:

Education and experience equivalent to:

• Associate’s degree in health, business, social sciences, or humanities, preferred.
• Two (2) years of experience working with Medi-Cal or Medicare in a managed care environment preferred. Work performing grievance and appeals processing preferred.
• Work in a call center, claims department, and/or other customer service position required.

Knowledge of:

• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint.
• Medicare, Medi-Cal, Managed Care and medical terminology preferred.

Abilities:

• Work cooperatively with others.
• Work as part of a team and support team decisions.
• Communicate effectively, both verbally and in writing.
• Adapt to changes in requirements/priorities for daily and specialized tasks.
• Communicate effectively and professionally, both verbally and in writing.
• Summarize information clearly, thoroughly, and quickly in writing.
• Deal with difficult people and situations while providing quality customer service.
• Use sound judgment, identify next steps to be taken and develop appropriate solutions.
• Collaborate with multiple parties to solve problems; solve problems independently.

The Health Plan of San Mateo (HPSM) is an equal opportunity employer and is committed to providing equal employment opportunities to all applicants and employees without regard to race, color, religion, creed, political affiliation, sex, gender, gender identity or expression, pregnancy, childbirth and related medical conditions, marital status, registered domestic partner status, sexual orientation, age, ancestry, national origin, citizenship status, veteran or military status, disability, medical condition, genetic information, or any other characteristic protected by applicable federal, state, or local law. 

This policy applies to all aspects of employment, including recruitment, hiring, selection, placement, promotion, transfer, demotion, compensation, benefits, training, discipline, and termination. 

HPSM is committed to providing reasonable accommodations to qualified individuals with disabilities and to applicants and employees with sincerely held religious beliefs or practices, in accordance with applicable law. If you require an accommodation during the application or interview process, or in order to perform the essential functions of a position, please contact the HPSM recruiter to request assistance.