Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

This position is a remote position. Candidates must be willing to work weekends.

The CTM Coordinator, Appeals & Grievances manages the day-to-day intake, investigation tracking, and resolution of grievances, appeals, and complaints submitted to CMS through the CMS Complaints Tracking Module (CTMs). This role is responsible for timely resolution of all cases, coordinating across departments to ensure member issues are addressed efficiently and correctly primarily for CTMs and provides additional capacity to the team coordinating appeals and grievance intake.

Job Duties/Responsibilities

Monitors the CTM portal daily for new cases.

Acknowledges receipt of all Complaint Tracking Module (CTM) grievances and appeals cases.

Gathers pertinent information from members, providers, internal departments and delegated entities to determine the appropriate resolution in accordance with standard policies and procedures, notifies the appropriate parties, and ensures completion of all internal processes required to resolve the issue ahead of regulatory deadlines

Completes outreach (verbal and written correspondence) to members and providers in accordance with plan policy and Centers for Medicare & Medicaid Services (CMS) guidelines.

Conducts unbiased, accurate, timely, and comprehensive investigations of all facts related to CTMs cases, as well as grievances and appeals.

Thoroughly documents all actions taken to resolve cases in accordance with CMS regulatory timeframes and internal policy and procedure.

Tracks all cases to closure, ensuring timely and comprehensive documentation that satisfies CMS regulatory requirements.

Ensures all CTM cases; grievances and appeals are processed in accordance with CMS guidelines and plan policy.

Drafts clear, compliant written responses to CMS within required turnaround times.

Prepares clear, objective, accurate, and comprehensive case histories for presentation and consideration at committee meetings and workgroups

Prepare monthly and quarterly reports as requested.

Assists in preparing reporting for compliance needs and regulatory audits.

Identifies appeal, grievance and complaint trends, systemic issues and opportunities to improve member experience and reduce complaint volume. Contributes suggestions that support strong CMS STAR performance.

Participate in periodic reviews and updates of CTM, grievance and appeal policies and procedures to reflect applicable legal and CMS requirements. Participates in CMS audit preparation and regulator meetings and interviews.

Meets or exceeds all internal and regulatory deadlines

Performs other duties as assigned.

Job Requirements

Experience

Required:  At least one year of Member Services or similar experience. 2+ years of experience working with Medicare Advantage healthcare plans.

Preferred: Direct experience working with CTM cases at a Medicare Advantage healthcare plan.

Education

• Required: High school diploma or GED.
• Preferred: Associate degree (A.A.).

Specialized Skills

Required:

Strong oral and written communication skills. Ability to draft CMS facing correspondence.

High attention to detail with ability to manage multiple deadlines driven cases simultaneously.

Ability to type at least 40 words per minute and use a 10-key keypad by touch.

Ability to communicate positively, professionally, and effectively; demonstrate leadership; teach; and collaborate across departments.

Ability to establish and maintain constructive relationships with diverse members, management, employees, and vendors.

Ability to read and interpret safety rules, operating and maintenance instructions, and procedure manuals; write routine reports and correspondence; and speak effectively before groups of customers or employees.

Ability to perform basic arithmetic using units of U.S. currency and measurements of weight, volume, and distance.

Ability to apply logic and reasoning to address problems efficiently and strategically, tailoring approach to the unique needs of each case.

Effective problem-solving, organizational, and time-management skills, with the ability to work in a fast-paced environment and exercise flexibility when business needs evolve.

Preferred: Bilingual in English and Spanish.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

Essential Physical Functions

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; and talk or hear.

The employee is frequently required to walk, stand, and reach with hands and arms.

The employee is occasionally required to climb or balance and to stoop, kneel, crouch, or crawl.

The employee must occasionally lift and/or move up to 20 pounds.

Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Pay Range: $48,373.00 - $72,559.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].