Grievance and Appeals Coordinator
Job in
San Jose, Santa Clara County, California, 95199, USA
Listing for:
Santa Clara County Health Plan
Full Time
position
Listed on 2026-02-07
Job specializations:
-
Healthcare
Healthcare Administration, Healthcare Management
Salary/Wage Range or Industry Benchmark: 66273 - 99409 USD Yearly
USD
66273.00
99409.00
YEAR
Job Description & How to Apply Below
Grievance and Appeals Coordinator
Salary Range: $66,273 - $99,409
FLSA Status: Non‑Exempt
Department: Grievance and Appeals
Reports To: Supervisor, Grievance and Appeals
Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521
General Description of Position
The Grievance and Appeals Coordinator is responsible for the beginning‑to‑end process of receiving, researching and resolving new and existing member and provider grievance and appeals cases for all lines‑of‑business including any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and SCFHP policies and procedures as set forth for each line of business.
Essential Duties and Responsibilities Act as a back‑up to the Grievance and Appeals Intake Specialist during times of high volume work and/or staffing shortages to ensure appropriate intake of new and existing grievance and appeal cases, assessing the priority of each case and routing to the appropriate staff.Ensure grievance and appeals cases are accurate and include the necessary elements for processing and resolving, giving special attention to those identified as "Expedite". Create clear and concise documentation in applicable system(s).Use good judgment and department resources to identify all issues and required actions within a case, appropriately categorize cases and identify required actions in accordance with state and federal regulations.Produce and manage outbound documents, correspondence and reports in a manner that meets required time frames.Ensure adherence with state and federal regulatory time frames for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required time frames.Prepare case files for State Fair Hearings, Independent Review Entities or other escalated types of cases, including documentation of the Statement of Position and case narratives. Represent SCFHP in any hearing proceedings.Develop effective and professional working relationships with internal and external stakeholders and partners. Communicate effectively with members and providers orally and in writing.Contact members and providers to seek additional information or clarification regarding grievance and appeals cases and review and resolve issues by requesting medical records, notice of action, or any other pertinent information related to grievances and appeals from medical groups, delegated entities and/or providers.Perform complete, accurate and consistent data entry into system software applications in accordance with policies, procedures and instruction from the Manager of Grievance and Appeals Operations.Maintain case files by ensuring that they are documented in accordance with state and federal requirements and organized in a manner that adheres to SCFHP standards and audit requirements.Participate in retrospective audit and review of cases and complete and correct gaps or errors in data.Identify operational issues and trends with SCFHP, delegates and other external stakeholders. Communicate these issues internally and externally and assist in formulating appropriate remediation plans.Assist the Manager of Grievance and Appeals Operations and peers with special projects. Work collaboratively and cross‑functionally with other departments to facilitate appropriate resolutions. Work as a team to complete departmental tasks to meet deadlines and accomplish department objectives.Attend and actively participate in Grievance and Appeals Committee meetings, operational meetings and department meetings, trainings and coaching sessions.Perform other related duties as required or assigned.Requirements – Required (R) Desired (D)
High School diploma or GED. (R)Associate’s degree or equivalent experience, training or coursework. (D)Minimum two years of experience in customer service, provider service, health service, or pharmacy in a managed care or health care environment handling escalated or complex issues. (R)Knowledge of health plan benefits,…
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