Job Description
Point of contact for Health Plan member grievances and internally identified potential quality of care issues (PQI – Potential Quality Issues). Responsible for coordinating the process with receipt and initial processing (including data entry, record requests and follow ups) for member grievances and other quality of care concerns from internal and external sources.
Maintains documentation in databases as required, coordinates and communicates with provider offices and other involved entities, ensuring documentation is requested and received, while managing TATs within Health Plan timelines (24 hours to 10 days, depending on type of request). This person will be handling grievances and appeals for the front-line staff health plans (internal PQI – Potential Quality Issue) and will be gathering patient records and responses.
- Fully Remote
- Hours: 8-5 pm PST
- 3MC w/ possibility of extension
** Needs to be comfortable with possibly traveling 1x per quarter to Irvine, CA **
We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal.com.To learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/.
Required Skills & Experience
High School Diploma or GED.
1+ year of experience with grievances
Experience with appeals
Nice to Have Skills & Experience
Bilingual English and Spanish.
Familiarity with medical terminology and HIPPA compliance.
Comfortable using scheduling systems, basic office software, and phone systems.
Experience using an EMR (electronic medical record system)
EPIC preferred.
Benefit packages for this role will start on the 1st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.