Specialist, Grievances & Appeals

Company: San Francisco Health Plan
Location: San Francisco
Posted on: November 6, 2024

Job Description:

As the Specialist, Grievances and Appeals you will participate in the daily operations of the Clinical Grievances and Appeals team. Under the direction of the Interim Supervisor of Grievances and Appeals, you will help to investigate and resolve member and provider grievance and appeals, while following all regulations and standards for processing grievances and appeals. In this collaborative role, you will work with the Customer Service, Clinical Operations, Provider Network Operations and Compliance and Regulatory Affairs Departments.Please note that while SFHP supports a hybrid work environment, you will be required to be onsite and in-office a minimum of 4 days per month. This is a hybrid position, based in our Downtown San Francisco office.Salary: $29.94 to $33.68 per hourWHAT YOU WILL DO:

• Collect, organize, track and summarize information to help resolve member grievances and appeals. Implement grievance and appeal reporting enhancements and ensure deliverables and deadlines are met.
• Communicate and work with members, providers and other external parties involved in received grievance and appeals.
• Draft materials necessary for executing projects such as project plans, charters and meeting materials. Create presentations and facilitate meetings with program managers and individual contributors.
• Support daily implementation of small to medium scale or short-term projects such as research, communications, database management, meeting coordination, and event logistics.
• Coordinate materials, record agreements and actions for SFHP committees and meetings.
• Conduct basic compilation, organization, and data analysis to evaluate current programs and inform the development of new programs (data tables, run charts, bar charts and pivot tables).
• Organize and participate in meetings (prepare agenda, organize documents on SharePoint, document agreements and actions, track completion of actions).
• Present grievance and appeals data to key stakeholders through Grievance Review Committee (GRC) and the Grievance Program Leadership Team (GPLT).WHAT YOU WILL BRING:
  • Bachelor's degree in Business, Public Health, or in a related area or equivalent work experience.
  • At least one year of experience in health plan operations, health care clinical quality improvement, direct patient care, grievances and appeals, or other experience directly related to position.
  • Experience working with EMR and Medi-Cal.
  • Familiarity with health care and managed care terminology.WHAT WE OFFER:
    • Medical: You'll have a choice of medical plans, including options from Kaiser and Blue Shield of California, heavily subsidized by SFHP.
    • Dental: You'll have a choice of a basic dental plan or an enhanced dental plan which includes orthodontic coverage.
    • Vision: Employee vision care coverage is available through Vision Service Plan (VSP).
    • Retirement - Employer-matched CalPERS Pension and 401(a) plans, 457 Plan.
    • Time off - 23 days of Paid Time Off (PTO) and 13 paid holidays.
    • Professional development: Opportunities for tuition reimbursement, professional license/membership.ABOUT SFHP:Established in 1997, San Francisco Health Plan (SFHP) is an award-winning, managed care health plan whose mission is to provide affordable health care coverage to the underserved low and moderate-income residents in San Francisco County. SFHP is chosen by eight out of every ten San Francisco Medi-Cal managed care enrollees and its 175,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services.San Francisco Health Plan is proud to be an equal opportunity employer. We are committed to a work environment that supports, inspires, and respects all individuals and in which our people processes are applied without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, marital status, age, disability, national or ethnic origin, military service status, citizenship, or other protected characteristics.Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.San Francisco Health Plan is an E-Verify participating employer.Hiring priority will be given to candidates residing in the San Francisco Bay Area and California.
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Keywords: San Francisco Health Plan, Richmond , Specialist, Grievances & Appeals, Other , San Francisco, California