Specialist, Grievances & Appeals
San Francisco Health Plan
As the Specialist, Grievances and Appeals you will be responsible for participating in the day-to-day 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 adhering to new and existing regulations and standards for processing grievances and appeals. This is a highly collaborative role and will work closely with The Customer Service, Clinical Operations, Provider Network Operations and Compliance and Regulatory Affairs Departments.
WHAT YOU WILL DO:
- Collect, organize, track and summarize information to facilitate the resolution of member grievances and appeals. Implement grievance and appeal reporting enhancements and ensure deliverables and deadlines are met.
- Communicate and interact 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 day-to-day 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 analysis of data in order 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) as needed.
- Perform other administrative related duties and special projects as assigned.
WHAT YOU WILL BRING:
- Bachelor’s degree in a related area or 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 duties and knowledge
- Preferred: strong working knowledge of Essette and Medi-Cal
- Required: familiarity with health care and managed care terminology
- Strong time management, task management, and organization skills across multiple simultaneous projects.
- Ability to:
- Work with qualitative and quantitative data; data analysis
- Produce accurate and precise work with strong attention to detail.
- Find and fix problems.
- Work very efficiently and thoroughly, fill gaps, prevent overlaps.
- Work independently and as part of a team.
- Hold self and others accountable to deadlines.
- Present information (verbal and written) to executives, clinicians, and other stakeholders.
- Customer service acumen and solutions-oriented approach.
- Demonstrated comfort using MS Office Suite (Outlook, Word, Excel, PowerPoint)
- Medical Plans: You’ll have a choice of medical plans, including options from Kaiser and Blue Shield of California. Employee-only coverage in the the HMO plans is currently available at no cost and dependent coverage is 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 at no cost.
- Time Off: 23 days of Paid Time Off and 12 observed company holidays.
- Professional development: Opportunities for tuition reimbursement, professional license/membership.
Established in 1994, 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 170,000+ members have access to a full spectrum of medical services including preventive care, specialty care, hospitalization, prescription drugs, and family planning services. SFHP was designed by and for the residents it serves, and takes great pride in its ability to accommodate a diverse population that includes young adults, seniors, and people with disabilities.
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.