About the position
UPMC Health Plan is hiring a temporary Member Complaints and Grievances Intake Coordinator. This full-time, remote position works Monday through Friday during daylight hours and is expected to last six months. The role manages accurate and timely case entry and classification in the Complaints and Grievances (C&G) information system and maintains C&G data files. The stated pay is \$20.00 per hour.
The Intake Coordinator processes verbal and written member requests, classifies complaints and appeals according to product, department, regulatory standards, and appeal rights, and supports investigations and follow-up. The role also manages documentation and communications, meets regulatory deadlines, escalates priority matters, enters coverage determinations, and supports C&G operational goals and implementation of an appeals tracking system.
Responsibilities
• Conduct intake for verbal and written requests and create new cases in the C&G information system.
• Classify member complaints and appeals by line of business and product according to department and regulatory standards and appeal rights.
• Complete appropriate investigations, which may include reviewing prior appeals, claims, authorizations, and inbound calls.
• Maintain a general understanding of appeal rights for each line of business.
• Respond promptly to follow-up needs on each case to support compliance and member satisfaction.
• Ensure member and provider concerns are thoroughly and accurately addressed according to regulatory guidelines.
• Organize tasks to meet regulatory requirements and deadlines.
• Navigate health plan systems to support accurate case classification, including MHK, MC400, Skygen, Health Planet, FileNet, CCD, PA Hub, and HP Capture and Route.
• Use PA Keystone State resources to review and process member Fair Hearing documentation.
• Assess, enter, and maintain documents in files and databases so information is organized and accessible.
• Respond promptly and accurately to incoming messages through department FileNet folders, email, fax, or phone CUTs.
• Triage and respond to inquiries, or document and distribute them as needed.
• Retrieve, copy, collate, and file documents associated with complaints and grievances.
• Identify and timely escalate priority and expedited issues to product leadership.
• Support team efforts to improve performance against measured service operation goals.
• Enter data into information systems to support C&G processes.
• Enter coverage determinations into systems of record.
• Adapt to system outages and issues by identifying workarounds and maintaining operational continuity.
• Support implementation of the appeals tracking system.
Requirements
• High school graduate or equivalent.
• Two years of work experience in claims or customer service.
• Proficiency in typing.
• Excellent communication, organizational, and customer service skills.
• Detail-oriented, with knowledge of Microsoft Word and Excel.
• Positive and professional attitude.
• Problem-solving and decision-making skills, with a solid understanding of managed care principles.
• Knowledge of product lines and ability to use decision tools to classify product lines and apply regulatory rules.
• Critical thinking skills to adapt investigations to member statements and other findings.
• Ability to remain flexible and responsive as requirements and case-handling expectations change.
Nice-to-haves
• Five years of managed care or health insurance experience preferred.