Member Complaints & Grievances Coordinator I, DHS Plans- Remote

UPMC Health Plan is hiring a full-time Member C&G Coordinator I in the Member C&G department.  This position works Monday through Friday, daylight hours and will be a remote position.  

The Member C&G Coordinator, I will track, trend, and manage member complaints and grievances for all product lines. Ensure the efficient and effective resolution of member complaints and grievances. Use the data collection and analysis to target initiatives for opportunities for improvement within the Health Plan.

Responsibilities:

• Investigate member complaints and grievances, and provider appeals, and respond in writing according to department standards.
• Effectively utilize key internal and external Health Plan contacts, including Health Plan staff, providers, and external review organizations, to help in this process.
• Organize all tasks within regulatory requirements/deadlines.
• Ensure member and provider concerns are thoroughly and accurately addressed according to regulatory guidelines.
• Understand and interpret medical information, recognize trends, and identify opportunities for improvement within the Health Plan.
• Coordinate and facilitate review hearings and internal appeal committee meetings or prepare Independent. 
• Review Entity case files dependent online of Business.
• Assist in reporting complaint and grievance data to appropriate regulatory bodies and internal departments.
• Support implementation of appeals tracking system.

• Associate degree or equivalent professional work experience. 
• 1 year of experience in health care environment required. 
• Medical claims and/or customer service background preferred. 
• Demonstrated success problem solving and decision making with a solid understanding of managed care principles. 
• Excellent verbal and written presentation skills are essential. 
• PC literacy with proficiency in the use of Microsoft office products. 
• Familiarity with ICD-10, HCPCS, and CPT4 coding and medical terminology.
  
  
  Licensure, Certifications, and Clearances:
   
• Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran