AmeriHealth Caritas Coordinator Grievance in Harrisburg, Pennsylvania
Location: Harrisburg, PA
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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .
The Complaint & Grievance Coordinator, under the general direction of the Supervisor, Complaint & Grievance is responsible for processing and monitoring all complaints and grievances. This position serves as a key liaison with the internal departments such as Clinical, Members Services, and Quality and external entities such as providers, county representatives, and any other parties that may be involved in the complaint and grievance process. This position serves as the primary contact for members, families, the reviewer, committee members, county oversights, and other involved entities or individuals, during the entire complaint and grievance process. The Complaint & Grievance Coordinator will also be held accountable for the following:
Processing of all complaints and grievances, ensuring completion in a manner that meets all mandated requirements, while maintaining objectivity and impartiality.
Coordinating meetings, ensuring proper committee representation, proper facilitation, and timely resolutions.
Collecting necessary documentation and other materials that allow for an informed decision by the reviewer(s).
Ensuring members are aware of their rights throughout the complaint and grievance process.
Providing assistance to the member and/or treatment team in preparing for complaint and grievance meetings.
Understanding the functions of other departments within PerformCare to ensure appropriate processing of complaints and grievances.
Maintaining a general understanding of how services are requested, authorized, and provided.
Navigating through the data systems and records to facilitate appropriate and thorough processing of disputes.
Identifying quality indicators and triggers that may require additional follow-up.
Facilitating meetings by phone and face to face, which may require travel into the community.
Acting as a representative of PerformCare while coordinating, attending, and facilitating complaint or grievance meetings.
Completing any/all required documentation.
Maintaining compliance with all federal, state and local regulations as well as other regulatory requirements relative to complaint and grievance operations such as NCQA, Appendix H and Act 68.
Ensuring accurate complaint and grievance data entry and adherence to all PerformCare policies and documentation requirements.
Ability to research and clarify complex circumstances to facilitate appropriate dispute resolutions.
Complying with the responsibilities of on call duties as needed in order to process expedited grievances.
Other duties as assigned.
Ability to work both independently and in a team environment.
Demonstrated problem-solving and decision making skills.
Excellent Verbal and Written communication skills.
1-3 years Investigation/review of complaints & grievances.
Prior experience in a highly regulated industry required.
Strong understanding of inventory management.
Sound knowledge of strong telephone soft skills.
Proficiency with Microsoft Office skills including Word, Excel and Outlook.
Experience handling escalated call issues that may result in State complaints.
EOE Minorities/Females/Protected Veterans/Disabled