Appeals and Grievances Coordinator

***This position is remote/work from home within California.

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health’s Medicaid population health care management pathways. Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups hospitals health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Dignity Health MSO offers an outstanding Total Rewards package that integrates competitive pay with a state-of-the-art flexible Health & Welfare benefits package. Our cafeteria-style benefit program gives employees the ability to choose the benefits they want from a variety of options including medical dental and vision plans for the employee and their dependents Health Spending Account (HSA) Life Insurance and Long Term Disability. We also offer a 401k retirement plan with a generous employer-match. Other benefits include Paid Time Off and Sick Leave.

***This position is remote/work from home within California.

Position Summary:

The Appeals and Grievances Coordinator is responsible for managing and coordinating the appeals and grievance process within Dignity Health MSO. This role involves handling member and provider complaints, ensuring compliance with regulatory requirements, and facilitating timely and effective resolution of appeals and grievances. Acting a subject matter expert (SME) the Coordinator will work closely with internal teams and external stakeholders to ensure a high level of service and satisfaction. This position oversees a mix of operational, business and regulatory activities related to several Health Plan Partnerships. This position will work closely with health plan partners to ensure a seamless transition in implementing new and ongoing regulatory requirements. From a business perspective, this role is responsible for the ongoing delegation and performance of our contractual obligations with our Health Plan partners.

Responsibilities may include:
- Receive, document, and manage member and provider appeals and grievances in accordance with DHMSO's organizational policies and regulatory standards.
- Ensure all cases are processed within required timeframes and follow-up actions are completed properly.
- Maintain detailed and accurate records of all appeals and grievances, including documentation of investigations, outcome, and communications.
- Manages and works closely with Regulatory partners in the management of identified patient populations. Oversees a mix of operational, clinical, educational and business activities as they relate to this partnership.
- Prepare files for appeals to regulatory agencies, staying current with all applicable regulatory requirements.
- Conducts relevant research into complaints and collaborates, coordinates and communicates with various departments (i.e. Member Services, Care Management, Claims), as well as external entities (i.e. Providers and Vendors) to collect additional information as necessary.
- Ensure all appeals and grievances are handled in compliance with federal, state, and local regulations, including CMS guidelines and health plan requirements.
- Maintains a current knowledge of plan products, policies and procedures with the ability to relate acquired knowledge in a clear, concise and understandable manner to members, providers, and internal staff.
- Monitor and analyze trends in appeals and grievances to identify systemic issues and recommend corrective actions.
- Prepare and submit regular reporting on appeals and grievance activity, trends, and outcomes to management and regulatory agencies as required.

Minimum Qualifications:

- 2+ years administrative experience in a compliance auditing arena. Previous experience in a similar administrative or coordination role. Familiarity with compliance requirements is a plus.
- Familiarity with healthcare regulations, including HIPAA, CMS, and state-specific requirements.
- Associate’s degree in relevant field or 3 years of related job or industry experience in lieu of degree.

Preferred Qualifications:

- Knowledge of DMHC, NCQA, CMS and other regulatory bodies preferred
- Knowledge of HIPPA, managed care environment preferred
- Strong technical proficiency in data analysis; database software preferred
- 2 years managed care experience preferred
- 1 years delegation oversight experience preferred
- Regulatory audit experience preferred
- Bachelor's degree in a relevant field (e.g., healthcare management, business administration, compliance) or 5 years of related job or industry experience in lieu of degree, preferred
- Certified Compliance Professional (CCP) preferred
- Certified Professional in Healthcare Quality (CPQH) preferred
- Certified Healthcare Auditor (CHA) preferred