1-3 years of experience
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Employment Type:
Full time
Job Category:
Health Care Provider
Grievance and Appeals Coordinator - 6 month contract
(This job is no longer available)
Enclipse Corp. | Pleasanton, CA
Grad Date

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Job Description

Member Relations - Case Coordinator


  • Responsible for the triaging and preparation of clinically urgent member case grievances and appeals (24-72 hour turn around) and Federal and State mandated external independent medical review Health Plan.

  • Participates in managing the organizations expedited grievance and appeals process including: opening cases and collection of appropriate documentation, may participate in the Expedited Review Committee with Department Managers, Clinical Consultants and Physician reviewers, responds to members, their physicians, and authorized representatives regarding the Health Plan's determination.

  • Prepares all cases in accordance with regulations, compliance standards, and policies and procedures.

  • Meets time frames for performance while balancing the need to produce high quality work related to complex and sensitive customer issues.

  • Assist with preparing cases for audits and other state and federal governments.

  • Partners with other health plan departments, Hospital staff, and PMGs in handling complex issues, politically sensitive issues including documentation, file maintenance, negotiation, resolution and response.

  • Participates in departmental meetings, training's, and unit self-audits as requested.


  • High School Diploma required, Bachelor's degree preferred

  • Minimum 3 years of experience in an HMO setting. (experience working in a hospital or medical office setting).

  • Candidate must have very strong ability to communicate verbally and in writing.

  • Proven Customer Service Skills while working under pressure.

  • Ability to multitask and superior organizational skills are a must.

  • Manager looking for or prefers any of the following backgrounds: Customer Service (phones, face-to-face), Healthcare or Insurance Experience.

  • Candidates must have proven ability to deal with difficult customers and sensitive/complex situations on the phone.

  • Must have proven skills at defining and researching problems.

  • Minimum four (4) years of Customer Service/Call Center or similar role in a time-sensitive environment.

  • Must be able to work in a Labor/Management Partnership


Applicants must be eligible to work in the specified location