[Hiring] Member Complaints & Grievances Coordinator I @UPMC

Role Description

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.

• 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 data collection and analysis to target initiatives for opportunities for improvement within the Health Plan.
• Meet Medicare and SNP guidelines for quality and production.

Qualifications

• 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.

Requirements

• 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.
• Construct IRE Packets as needed.

Licensure, Certifications, and Clearances

• UPMC is an Equal Opportunity Employer/Disability/Veteran.