Appeals and Grievances Coordinator I

“Pay scale information is not necessarily reflective of actual compensation that may be earned, nor a promise of any specific pay for any selected candidate or employee, which is always dependent on actual experience, education, qualifications, and other factors.  A full review of our comprehensive pay and benefits will be discussed at the offer stage with the selected candidate.”

This position is not eligible for Sponsorship.

MedImpact Healthcare Systems, Inc. is looking for extraordinary people to join our team!

Why join MedImpact? Because our success is dependent on you; innovative professionals with top notch skills who thrive on opportunity, high performance, and teamwork. We look for individuals who want to work on a team that cares about making a difference in the value of healthcare.

At MedImpact, we deliver leading edge pharmaceutical and technology related solutions that dramatically improve the value of health care. We provide superior outcomes to those we serve through innovative products, systems, and services that provide transparency and promote choice in decision making. Our vision is to set the standard in providing solutions that optimize satisfaction, service, cost, and quality in the healthcare industry. We are the premier Pharmacy Benefits Management solution!

The Appeals and Grievances (A&G) team is responsible for managing all aspects of the appeals and grievances process, including—but not limited to—intake, processing, notification, and compliance. The Appeals and Grievances Coordinator I serves as a key member of the A&G team, processing appeal

and grievance requests in accordance with established standards for accuracy, timeliness, productivity, client performance commitments, and regulatory requirements (e.g., state and federal regulations, professional accreditations). This position reports directly to the Supervisor of Appeals and Grievances

Operations and is led by the Lead Coordinator (Coordinator III). The Coordinator I utilizes various business applications—such as MedAccess, MedResponse®, FileNet and RightFax - to perform analysis, retrieve information, and enter data as needed to complete assigned tasks. Strong reasoning skills are essential for evaluating appeal and grievance requests for appropriateness and ensuring adherence to required processes. The ability to multitask and cross-train in both appeals and grievances processing is essential to support the weekend rotation schedule. Interact with internal and external customers as required. Work under general supervision, relying on work instructions, policies & procedures, and available company resources to perform the functions of the position efficiently and effectively.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Evaluate and process Appeals and Grievances per establish work instructions and approved departmental documents.
• Perform and document outreach activities (including outbound calls and faxes) to obtain information necessary for processing Appeals and Grievances or to communicate the results of Appeal and Grievance reviews.
• Ensure Appeals and Grievances are finalized within the required turnaround time (TAT) in accordance with applicable laws and company policies.
• Must be able to cross-train across the appeal and grievance task divisions.
• Participating in the rotating weekend on-call schedule as needed.
• Protect and maintain confidentiality and privacy of all members’ personal and health information in accordance with federal requirements and company policies.
• Must comply with company and department policies, procedures, rules and regulations.
• Must possess the ability to adapt to departmental changes as required for the needs of the business. Must be flexible with shift changes.

Supervisory Responsibilities        

No supervisory responsibilities

Client Responsibilities

This is an internal and external client facing position that requires excellent customer service skills and interpersonal communication skills (listening/verbal/written).  One must be able to; manage difficult or emotional client situations; Respond promptly to client needs; Solicit client feedback to improve service; Respond to requests for service and assistance from clients; Meet commitments to clients.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

GED/HS Diploma and 1+ year experience or equivalent combination of education and experience

Computer Skills

To perform this job successfully, an individual should have knowledge of MS Office Suite. Proficiency of knowledge of Microsoft Word and Microsoft Excel.

Certificates, Licenses, Registrations

Certified Pharmacy Technician state licensure as a Pharmacy Technician required. Additionally a Certified Pharmacy Technician Certification is preferred.

Ability to obtain Kentucky licensure within three (3) months of hire.

Other Skills and Abilities

• Oral Communication: Speak clearly and persuasively in positive or negative situations. Listen and obtain clarification when needed. Responds well to questions.
• Written Communication: Write clearly and informatively. Edit work for spelling and grammar.
• Teamwork: Balance team and individual responsibilities. Exhibit objectivity and openness to others' views. Give and welcome feedback. Contribute to building a positive team spirit. Put the success of the team above own interests. Support everyone’s efforts to succeed.
• Organizational Support: Follow policies and procedures. Complete required tasks correctly and on time. Support organization's goals and values. Benefit organization through outside activities. Support affirmative action and respect diversity.

Reasoning Ability                                   

• Ability to apply common sense understanding to carry out detailed but uninvolved written or oral instructions.  Ability to deal with problems involving a few concrete variables in standardized situations.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.

Mathematical Skills      

• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals.  Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.
• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.

Language Skills

• Ability to read and comprehend simple instructions, short correspondence, and memos. Ability to write simple correspondence.       
• Ability to effectively present information in one-on-one and small group situations to customers, clients, and other employees of the organization.

Competencies To perform the job successfully, an individual should demonstrate the following competencies:

Composure

Decision Quality

Organizational Agility

Problem Solving

Customer Focus

Drive for Results

Peer Relations

Time Management

Dealing with Ambiguity

Learning on the Fly

Political Savvy

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this Job, the employee is regularly required to sit and talk or hear. The employee is regularly required to stand; walk; use hands to finger, handle, or feel and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position may regularly be exposed to or encounter moving mechanical parts, high, precarious places, fumes or airborne particles, toxic or caustic chemicals, outdoor weather conditions, risk of electrical shock or vibration. The noise level in the work environment is usually moderate (examples: business office with computers and printers, light traffic).

Work Location

This position works on-site at the San Diego Headquarters or other company location (or from a remote location with management approval based on business requirements). Must provide adequate support to internal clients; be available for regular interactions and coordination of work with other employees, colleagues, clients, or vendors; as well as be available to facilitate effective decisions through collaboration with stakeholders.

Working Hours

This is a full-time non-exempt position requiring one to be able to work overtime from time to time in order to get the job done.  Therefore, one must have the ability to work nights, weekends or on holidays as required.  This may be changed at any time to meet the needs of the business.  The typical working hours for this position are Monday through Friday from 8:00am to 5:00pm.

Travel

This position requires no travel however attendance maybe required at various local conferences and meetings.

• Medical / Dental / Vision / Wellness Programs

• Paid Time Off / Company Paid Holidays

• Incentive Compensation

• 401K with Company match

• Life and Disability Insurance

• Tuition Reimbursement

• Employee Referral Bonus

To explore all that MedImpact has to offer, and the greatness you can bring to our teams, please submit your resume to www.medimpact.com/careers

MedImpact, is a privately-held pharmacy benefit manager (PBM) headquartered in San Diego, California. Our solutions and services positively influence healthcare outcomes and expenditures, improving the position of our clients in the market. MedImpact offers high-value solutions to payers, providers and consumers of healthcare in the U.S. and foreign markets.

To perform this job successfully, the successful candidate must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified.