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UPMC Health Plan is hiring a full-time Member C&G Coordinator I, Medicare/SNP. This position works Monday through Friday, daylight hours. This will be a hybrid position so candidates will need to reside in the greater Pittsburgh area.

This position will track, trend, and manage member grievances, appeals, and IRE requests for the Medicare and SNP product lines. They will ensure the efficient and effective resolution of member grievances, appeals, and IRE requests according to department and regulatory timeframes. They will compose professionally written letters for members and employ the use of all Medicare and SNP processes and meet timeliness guidelines. They will manage multiple case types simultaneously. They will adhere to CMS guidance and comply with all regulatory timeframes. They will also use the data collection and analysis to target initiatives for opportunities for improvement within the Health Plan. Additionally, they will meet Medicare and SNP guidelines for quality and production.

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.

+ Prepare Independent Review Entity case files dependent online of Business.

+ Assist in reporting complaint and grievance data to appropriate regulatory bodies and internal departments.

+ Maintain quality and performance metrics as outlined by Supervisor.

+ Constructs IRE Packets as needed.

+ Associate degree or equivalent professional work experience.

+ 1 year of experience in a health care environment required.

+ Preference will be given to candidates residing in the Pittsburgh area.

+ Health Insurance or Medicare background preferred.

+ 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.

+ Experience with Medicare and SNP preferred.

Licensure, Certifications, and Clearances:

UPMC is an Equal Opportunity Employer/Disability/Veteran