Regulatory Complaints Coordinator

Job Description

Job Description

JOB TITLE: Regulatory Complaints Coordinator

FLSA STATUS: Non-Exempt

DEPARTMENT: Member Experience

REPORTS TO: Manager, Appeals & Grievances

JOB SUMMARY:

• Responsible for supporting resolution of regulatory complaints, including but not limited to Medicare CTMs and Marketplace HICS, in accordance with the standards and requirements established by Medicare, and applicable state insurance regulations for the Exchange.
• Responsible for intake, tracking, determining the root cause of complaints and making decisions on implementation of any necessary corrective action plan.
• Conducts Operational Audits on Member Experience departments, including, but not limited, Enrollment, Member Services, Provider Network and A&G.

ESSENTIAL JOB FUNCTIONS:

1. Provide administrative support for all regulatory complaints to ensure all cases are processed per regulatory guidelines and internal department protocol including:
   1. Coordinate,
   2. document and
   3. track all cases.
2. Assit with researching issues utilizing internal systems, outreach to providers, vendors and internal departments in order to fully support response to all issues raised in a grievance or to resolve appeal.
3. Requests medical records, clinical notes, and responses from providers, vendors and internal departments as directed.
4. Maintains working knowledge of regulatory guidelines surrounding complaints per Medicare and state regulations and per internal policies & procedures.
5. Acts as a liaison between departments to coordinate information and supports closing cases within regulatory timelines.
6. Adheres to payroll policies and properly uses timekeeping system with minimal manual changes.
7. Maintains regular and consistent attendance.
8. Adheres to Compliance Plan and HIPAA regulations.

MARGINAL JOB FUNCTIONS:

1. Takes on special projects as needed.
2. Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS:

Continuous Learning:

Attends staff meetings as required.

Attends appropriate training, seminars and workshops as required

Customer Focus:

Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations

Quality/Process Improvement/Safety

Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.

Supports and demonstrates safety throughout all duties performed.

Understands and complies with all regulators standards set forth by governing entities.

Administrative Adherence:

Adheres to payroll policies and properly uses timekeeping system with minimal manual changes.

Maintains regular and consistent attendance.

Adheres to Imperial’s Compliance Plan and Standards of Conduct.

Fosters appropriate communication and relations with Supervisor, co-workers and other staff.

POSITION REQUIREMENTS:

1. Education/Experience:
   1. High school graduate or equivalent.
   2. 1 year of Medicare A&G experience required
   3. Must have experience in making outgoing phone calls as well as taking incoming phone inquiries

1. Skills/Knowledge/Ability:
   1. Proficiency in Microsoft Suite
   2. Willingness and ability to read, write, speak, understand English and have the communications skills necessary to provide accurate information.
   3. Willingness and ability to follow written and verbal direction in English.
   4. Willingness and ability to interact professionally with all, members, and co-workers, individually and as part of a team.
   5. Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.
   6. Willingness and ability to make appropriate judgments, decisions and problem solving in a timely manner and within the context of the situation at hand.
   7. Ability to effectively prioritize items/tasks as required.
   8. Willingness and ability to take initiative and be a self-starter.
   9. Willingness and ability to understand and comply with Federal, State, and local regulations.

1. Licensure/Certificate/Training:
   1. n/a

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