Facility: Health Plan

　　City San Diego

　　Department

　　Job Status

　　Regular

　　Shift

　　Day

　　FTE

　　1

　　Shift Start Time

　　Shift End Time

　　Bachelor's Degree

　　Hours

　　Shift Start Time:

　　8:30 AM

　　Shift End Time:

　　5 PM

　　Additional Shift Information:

　　Weekend Requirements:

　　No Weekends

　　On-Call Required:

　　No

　　Hourly Pay Range (Minimum - Midpoint - Maximum):

　　$27.986 - $34.983 - $41.979

　　The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

　　What You Will Do

　　Responsible for the investigation, documentation and resolution of member appeals and grievances in compliance with State law, rules, and guidelines; provider and group agreements; Operations Manual; benefit matrices; and other administrative and medical guidelines, policies, and procedures. Works closely with the Chief Medical Officer (CMO) who is responsible for all decisions regarding clinical appeals and grievances and the Chief Operations Officer (COO) who is responsible for non-clinical appeals and grievances.

　　Required Qualifications

　　3 Years Experience in claims, utilization review, appeals or member services in a managed care environmentPreferred Qualifications

　　Bachelor's Degree Business Administration or Health Care Administration (including courses of study in accounting, finance, marketing, and health care administration)Essential Functions

　　Appeal and grievance processingUnder limited supervision, reviews and responds to appeals and grievances received from members and providers, in accordance with applicable policies and procedures.Ensures compliance with all required timeframes for acknowledgement and resolution of appeals and grievances.Ensures that policies and procedures, letters and member materials regarding appeals and grievances are in compliance with DHS, CMS, and DMHC requirements and NCQA accreditation standards.

　　Case files and documentation.Prepares and maintains case files and database for appeals and grievances in accordance with SHP, DHS, CMS, and DMHC requirements and NCQA accreditation standards.Maintains appropriate documentation in IDX Customer Service Module to ensure accurate and thorough documentation of appeals/grievance process.Communicates both in written and oral form in a professional manner with members, providers, other health plan departments, and representatives of regulatory agencies.

　　Customer serviceProvides prompt, accurate and excellent services to internal and external customers. Develops solid professional working relationships with various internal departments and units and, as required, vendors, providers, employers, brokers and/or other customers.

　　General supportParticipates in special projects and other duties as assigned. These may include, but are not limited to, work groups, proposals, audits and back-up support for other departments.

　　Member inquiry workgroupChairs the Member Inquiry Workgroup and, with the other Workgroup participants, reviews the documentation and resolution of member inquiries and requests for assistance.Provides feedback to Customer Service, Enrollment, Provider Relations, Claims Research, and Health Services on issues and trends identified in the Member Inquiry Workgroup.

　　ReportsPrepares reports on grievance and appeals as required by regulatory agencies, NCQA standards, and Plan management. Prepares weekly reports on open cases.

　　ResearchConducts research between different departments in order to resolve issues involving medical groups, providers, employer groups, DHS, CMS, DMHC, and members by utilizing all documentation necessary.Establishes and maintains positive working relationships with internal departments and delegated entities to facilitate communication and follow-up.

　　Knowledge, Skills, and Abilities

　　Thorough understanding of managed care principles and models.

　　Thorough understanding of health services and delivery models, including hospital, physician, ancillary, home health, prescription drugs, etc. Knowledge of various managed care reimbursement methodologies.

　　Ability to analyze and interpret data, and prepare summary reports from findings.

　　Familiarity with DMHC, DHS, CMS, and other regulatory agency standards related to appeals and grievances.

　　High level of integrity, ethical practices, innovative thinking, ability to exercise sound judgment and maintain confidentiality.

　　Able to exercise mature and sound judgment in the commitment of the Plan's mission and operating goals.

　　Exceptional diplomacy skills to effectively resolve issues under sometimes tense and stressful circumstances.

　　Able to follow strict timelines and manage multiple tasks concurrently.

　　Flexible.

　　Able to work independently and as a member of a cohesive, results-oriented team.

　　Excellent organizational and interpersonal skills.

　　Computer skills must include experience with electronic mail, word processing, spreadsheets, database programs and the IDX Managed Care application. Familiarity with Internet preferred.

　　Adept in both written and oral communications.

　　Strong writing skills.

　　Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class