[Hiring] Member Complaints & Grievances Intake 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 and is a remote position.

The C&G Coordinator I will manage accurate and timely case entry and classification in the Complaints and Grievances (C&G) information system. Accurately maintain C&G data files.

• Conduct case intake process for statements received through verbal and written requests and set up new cases in the C&G information system.
• Classify member complaints/appeals based on line of business/product according to department and regulatory standards and appeal rights.
• Complete appropriate investigation which may include investigation of previous appeals, claims, authorizations, and inbound calls.
• Have a general understanding for the different appeal rights associated with each line of business.
• Ensure prompt response to all follow-up needs on every case for compliance needs and member satisfaction.
• Ensure member and provider concerns are thoroughly and accurately addressed according to regulatory guidelines.
• Organize all tasks within regulatory requirements/deadlines.
• Access and navigate multiple health plan systems to support accurate case classification.
• Utilize PA Keystone State resources to properly review and process member Fair Hearing documentation.
• Accurately and promptly assess, enter, and maintain documents in files and/or databases.
• Respond and address incoming messages via department FileNet folders, emails, fax system, or phone CUTs.
• Triage and respond to inquiries as appropriate or note and distribute as needed.
• Retrieve, copy, collate, and file various documents associated with the complaints and grievances processes.
• Identify and escalate priority and expedited issues to all product leadership in a timely manner.
• Support the team's efforts to improve performance against measured service operation goals.
• Complete data entry into various information systems to support C&G processes.
• Enter coverage determinations into systems of record.
• Adapt quickly to system outages and issues by identifying effective workarounds and maintaining operational continuity.
• Support implementation of appeals tracking system.

Qualifications

• High school graduate or equivalent required.
• Two years of work experience in claims or customer service required.
• Five years of managed care or health insurance experience preferred.
• Proficiency in typing required.
• Excellent communication, organizational, and customer service skills.
• Detail-oriented, knowledge with Microsoft Word and Excel.
• Demonstrate a positive and professional attitude.
• Problem solving and decision-making skills with a solid understanding of managed care principles.
• Knowledge of all product lines and ability to follow decision tools to assist with appropriate classification of all product lines and regulatory rules.
• Critical thinking skills are crucial, as every case and investigation needs may vary, depending on member statements and other investigation findings.
• Ability to remain flexible and responsive as requirements and case-handling expectations change regularly.

Licensure, Certifications, and Clearances

• Act 34

Company Description

UPMC is an Equal Opportunity Employer/Disability/Veteran.