Position Summary 

The Grievance Coordinator is responsible for the management, investigation, documentation, and resolution of all health plan grievances, complaints, appeals support, and regulatory inquiries for clinics across the region. This role serves as the central point of contact for health plan grievance communications and ensures timely, accurate, and compliant responses in accordance with federal, state, health plan, and organizational requirements. 

The Grievance Coordinator partners closely with clinic leadership, providers, operations teams, patient relations, quality, compliance, and health plans to investigate concerns, gather supporting documentation, identify root causes, and prepare comprehensive grievance responses. The position plays a critical role in maintaining regulatory compliance, improving patient satisfaction, identifying operational opportunities for improvement, and strengthening relationships with health plan partners. 

The ideal candidate possesses strong investigative skills, exceptional written communication abilities, healthcare operations knowledge, and the ability to manage multiple deadlines in a fast-paced environment. 

 Essential Functions

• Serve as the primary coordinator for all health plan grievances, complaints, and member concerns received across the region.  
• Receive, review, investigate, and respond to grievances within required regulatory and contractual timelines.  
• Collaborate with clinic leaders, providers, departments, and operational teams to gather information needed for grievance investigations.  
• Prepare clear, accurate, and professional written responses to health plans regarding member complaints and grievances.  
• Review medical records, documentation, policies, procedures, and operational processes to support investigations.  
• Ensure grievance responses meet health plan, CMS, state, delegated entity, and organizational requirements.  
• Maintain detailed records of grievance investigations, findings, corrective actions, and resolutions.  
• Monitor grievance deadlines and ensure timely submission of responses and supporting documentation.  
• Identify trends, recurring issues, and operational concerns through grievance analysis.  
• Escalate high-risk, regulatory, compliance, or quality concerns to leadership as appropriate.  
• Coordinate with Patient Relations, Quality, Compliance, and Clinical Operations teams to implement corrective actions.  
• Participate in audits and prepare documentation for health plan reviews and regulatory requests.  
• Maintain confidentiality and compliance with HIPAA and privacy regulations.  

Key Responsibilities

• Manage the grievance process from receipt through resolution for all assigned health plans and clinics.  
• Track and prioritize multiple grievance cases while ensuring compliance with turnaround time requirements.  
• Draft professional grievance response letters and health plan communications.  
• Conduct routine follow-up with clinic leadership and stakeholders regarding open grievance investigations.  
• Maintain grievance logs, databases, reporting tools, and supporting documentation.  
• Ensure complete, accurate, and timely documentation of all grievance activities.  
• Analyze grievance trends and identify opportunities for process improvement and member satisfaction enhancements.  
• Assist leadership in developing corrective action plans related to grievance findings.  
• Prepare recurring reports and dashboards related to grievance volume, timeliness, outcomes, and trends.  
• Participate in health plan meetings and delegated oversight activities as assigned.  
• Provide education and guidance to clinic staff regarding grievance management processes and best practices.  
• Support patient experience initiatives by identifying barriers impacting member satisfaction.  
• Collaborate with operational and clinical leaders to address systemic issues contributing to grievances.  
• Maintain current knowledge of health plan requirements, regulatory updates, and industry best practices. 

Required Qualifications

• High School Diploma or equivalent required.  
• Minimum of one (1) year of healthcare operations, patient relations, grievance management, quality, compliance, or health plan experience.  
• Experience investigating and responding to patient complaints, grievances, or regulatory inquiries.  
• Knowledge of managed care, healthcare operations, regulatory compliance, and health plan requirements.  
• Strong written communication skills with the ability to draft professional and detailed correspondence.  
• Excellent organizational and time management skills.  
• Ability to manage multiple projects and deadlines simultaneously.  
• Proficiency with electronic health records (EHR), Microsoft Office Suite, and reporting systems.  
• Strong analytical, problem-solving, and investigative skills.  
• Ability to maintain confidentiality and exercise sound judgment when handling sensitive information. 

 Preferred Qualifications 

• Experience working with Medicare, Medicaid, Commercial Health Plans, or Delegated Medical Groups.  
• Prior experience in grievance and appeals management.  
• Knowledge of CMS, DHCS, NCQA, and health plan grievance requirements.  
• Experience with quality improvement and performance improvement initiatives.  
• Experience preparing regulatory responses and corrective action plans.  

Physical Requirements: 

• Ability to sit and/or stand for prolonged periods of time.
• Ability to move/carry objects up to 20 pounds.
• Moving from one work site to another as needed.
• Ability to communicate with others to exchange information
• Ability to use and/or type on a laptop/keyboard.