What are the responsibilities and job description for the Commercial Complaint Coordinator position at Viva Health?
Commercial Complaint Coordinator
Location: Birmingham, AL
Work Schedule: Hybrid schedule with regular work onsite at the VIVA HEALTH corporate office and some work-from-home opportunities.
Why VIVA HEALTH?
VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.
VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan, receiving a 5 out of 5 Star rating - the highest rating a Medicare Advantage Plan can achieve and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.
Benefits
- Comprehensive Health, Vision, and Dental Coverage
- 401(k) Savings Plan with company match and immediate vesting
- Paid Time Off (PTO)
- 9 Paid Holidays annually plus a Floating Holiday to use as you choose
- Tuition Assistance
- Flexible Spending Accounts
- Healthcare Reimbursement Account
- Paid Parental Leave
- Community Service Time Off
- Life Insurance and Disability Coverage
- Employee Wellness Program
- Training and Development Programs to develop new skills and reach career goals
- Employee Assistance Program
See more about the benefits of working at Viva Health - https://www.vivahealth.com/careers/benefits
Job Description
The Commercial Complaint Coordinator is responsible for processing commercial complaints according to state and federal regulatory requirements, including intake, research of the complaint, and follow through to final disposition. This individual facilitates the Formal Complaint Committee meetings, including scheduling with the member and internal staff, distribution of materials and minutes, maintaining policies, and logging all complaints.
In addition, this role will assist with reporting commercial complaints and pulling data as needed for both internal and external audits. This position assists the department with appeals and grievances for other lines of business, as needed and participates in an on-call rotation for weekend and holiday coverage.
Key Responsibilities
- Process informal, formal, and expedited commercial member complaints in accordance with state and federal guidelines including coordinating investigations, drafting responses, and coordinating third party reviews as required.
- Coordinate Formal Complaint Committee meetings including scheduling with the member and internal staff and distribution of materials and minutes. Maintain policies and procedures, a log of all complaints (with disposition), and complaint files.
- Assist with reporting commercial appeals and grievances for internal and external audits. May provide analyses of data including trend reporting.
- Comply with federal, state, and local legal requirements by maintaining current knowledge of commercial regulatory guidance, enforcing adherence to requirements, and advising management on needed actions.
- Review and provide feedback on proposed coverage language changes to commercial coverage documents (e.g., Certificate of Coverage, Summary of Benefits, and drug riders).
- Provide additional support to the Appeals and Grievances Department by assisting with maintaining procedures and completing projects in support of plan audits.
REQUIRED:
- Bachelor's Degree or equivalent experience
- 5 years’ experience in specialized field such as health insurance customer service, or complaints and appeals
- Excellent written and verbal communication skills
- Good analytical ability
- High proficiency in the Microsoft Office suite of products including Excel, Word, and PowerPoint
- Ability to exercise sound independent judgement and discretion in decisions that affect business operations
- Excellent organizational and interpersonal skills, including the ability to work on and track multiple assignments on various timelines with minimal supervision
PREFERRED:
- LPN/RN or comparable health care professional degree
- Advanced knowledge of a technical or specialized field such as insurance, public health policy, complaints and appeals, compliance, or government affairs
- 2 years of experience with a health plan
- Experience interpreting governmental regulations and applying them to business operations
