Organizations hire a Grievance Coordinator for evaluating grievances filed against the company. Working in a variety of settings, these professionals serve as the middleman between the individual filing the grievance and the company. Duties associated with the role are mentioned on the Grievance Coordinator Resume as – providing a written response to grievance letters, following up with each grievance by researching the event, reviewing any security footage and gathering witness accounts, evaluating the situation based on research, recommending various actions to superiors, and providing documentation necessary for the appeal process.
Many of these positions require a bachelor’s degree with a major in business or a field directly relating to the company, such as healthcare. Experience and knowledge of the field are required. Outstanding interpersonal skills and the ability to communicate well with dissatisfied individuals are key to success in this career.
Headline : Over five (5) years of experience in the Grievance Coordinator and two (2) years in the Medicare Program including Customer Service, Operations and Project Management, Understands the importance of Customer Retention successfully building rapport with clients, Strong written and verbal communication skills with the ability to deliver complex information to diverse audiences, Proficient in Microsoft Office and Adobe XI Pro, Fluent in the Haitian-Creole language.
Skills : Assessments, Crisis Intervention, Group and Individual Counseling, Re-entry Planning, Case Management, Advocacy, Communication.
Description :
Researched member & provider complaints including Access to Care, Quality of Care, Provider Network, Benefits, Enrollment, Billing & Claims, etc.
Resolved dissatisfactions regarding Customer Service such as Outsourcing, Misinformation, Hold Time, Multiple Transfers, Unfulfilled Requests, etc.
Initiated Pharmacy Coverage Determinations such as Drug Evaluation Review, Tier Exceptions, and Appeals.
Escalated issues to internal & external departments including Provider Relations, Utilization Management, Case Management, Special Investigations Unit, Medical Transportation Management, CVS Caremark, First Recovery Group, etc.
Identified root cause for grievances against Quest Diagnostics for balance billing.
Claims denied for prior authorizations required but not obtained - claims were submitted with non-participating provider identification (ID) number in which was later found services were capitated through a different ID number.
Educated Quest Diagnostics and members on the claims process.
Experience
5-7 Years
Level
Executive
Education
GED
Grievance Coordinator Resume
Objective : Secure employment that maximizes the use of my education, skills, and experience to optimize my opportunity for professional growth. Continue to gain knowledge to assist and train others as well as myself to succeed.
Skills : Health Insurance, Medical Authorizations, Public Sector Benefits., Salesforce, Microsoft Access.
Description :
Responded to member, provider and other inquiries via telephone, correspondence while meeting all corporate guidelines and performance standards.
Demonstrated appropriate customer service skills such as empathy, active listening, courtesy, politeness, helpfulness and other skills as identified.
Recorded, researched and resolved both member and provider complaints as detailed in the Grievance Procedure narrative.
Assisted with Agency for Health Care Administration (AHCA) Medicaid cases and reporting to the State.
Assisted in the education of new members and in the re-education of existing members regarding health plan procedures.
Tracked grievance case by line of business for compliance and review.
Assisting in resolving member and provider complaints.
Experience
2-5 Years
Level
Executive
Education
BS In Arts And Sciences
Grievance Coordinator Resume
Headline : Responsible for Evaluating, Processing inmate, and resident grievances according to policies and contractual requirements, and also Facilitating informal resolutions before escalation to formal grievance process where permissible.
Skills : Microsoft Office, Typing, Adding Machine, Shorthand.
Description :
Made decisions that are consistent with the concept of a win-win-win for members, associates, and WellCare.
Demonstrated based behaviors such as initiative, accountability, and value.
Triage the department's internal and external mail using the SharePoint Site and Tracker.
Managed grievance files Health Services Advisory Group (HSAG) Medicaid Audit for Harmony Health Plan.
Streamlined and improved the desktop procedure on grievances.
Managed grievance/complaint process, Medicaid HMO, Reported to M.
Researched annual average of 600 cases for committee review, DPW fair hearings.
Experience
5-7 Years
Level
Executive
Education
Certificate In Paralegal
Grievance Coordinator Resume
Objective : Proficient in English and Spanish, analytical, and very outgoing with a positive attitude. Great interpersonal and people skills, incredible listener and have remarkable communication skills. I am very prompt and persistent; I have flexibility in managing multiple tasks.
Skills : Computer Skills, Coordinating Skills.
Description :
Handled all Ohio Amerigroup unresolved grievances (55k to 60k enrollees).
Analyzed the member's grievances and provide solutions.
Reduced noncompliance fines to zero in 8 months, saving the company a quarter of a million in 3 years.
Maintained 100% compliance Develop and maintain customer/member relations.
Educated members on their bills, member benefits and provider services.
Crossed department coordination, ensuring resolutions in a timely and more efficient manner.
Audited Ohio call logs from the National Call Center.
Experience
2-5 Years
Level
Executive
Education
Bachelor Of Applied Arts
Grievance Coordinator Resume
Objective : To establish a long-term career in a company where I may utilize my Grievance Coordinator professional skills and knowledge to be an effective Associate Program Manager and inspiration to those around me.
Skills : MS office, Reviewing Skills.
Description :
Logged in and assigned identification and tracking grievance number.
Categorized grievances for analytical and statistical information.
Reviewed prisoner grievance for rejection or acceptance.
Identified and assigned appropriate staff personnel to respond to grievances.
Reviewed staff responses to grievances for completeness and compliance with departmental policy and procedure, administrative rules, or statutes.
Monitored the grievance process to ensure grievances are processed within the prescribed time limit and in accordance with applicable departmental policy and procedures.
Responded to inquiries from prisoners regarding their grievances and the grievance process in general.
Experience
2-5 Years
Level
Executive
Education
Business Administration
Grievance Coordinator Resume
Headline : Currently looking for a social work position that provides the opportunity for direct client contact. I have years of experience and am known professionally for my easy rapport with both clients and co-workers, my excellent advocacy and communication skills, as well as my work ethic, creativity, and passion for the field of social work.
Skills : Excellent Computer, Ability To Use Multiple Electronic Systems, Software Programs, And The Internet To Review And Record Information. Experience In Analysis Of Utilization And Quality Management Data.
Description :
Researched and responded to clinical grievances submitted by members and providers in accordance with health plan benefits.
Developed and managed implementation of healthcare fraud policies.
Collaborated with physicians reviewing clinical grievances in the managed care environment.
Researched and responded to state regulatory agency requests regarding member/provider issues and complaints.
Played an essential role in the development and implementation of a corporate-wide compliance program to ensure Lifeguard's compliance with all state and regulatory requirements.
Reorganized an underutilized Special Investigative Unit program and returned it to peak performance.
Worked with legal counsel to communicate the latest legislation to affected departments within Lifeguard.
Experience
5-7 Years
Level
Executive
Education
MS
Grievance Coordinator Resume
Objective : Seeking a position with your department where I can effectively utilize my current supervisory and analytical skills within your healthcare facility.
Skills : Administrative Support, Planning Skills.
Description :
Processed grievances and appeals in accordance with NYS insurance policies and procedures.
Coordinated meeting times for review of appeals.
Provide timely and accurate feedback on appeal status.
Maintained database of appeals and grievances for reporting to the state of New York.
Documented, tracked and reported appeals and complaints received from New York State employees.
Maintained member confidentiality, physician and employee information.
Consistently maintained an accuracy rate of 90% as documented by routine audits.
Experience
2-5 Years
Level
Executive
Education
MS
Grievance Coordinator Resume
Headline : To obtain a Grievance Coordinator position where I may apply my skills, further my knowledge and expand my interests in the grievance field. I am a reliable and dependable contributing team member with the drive to excel.
Skills : Training Skills, Creative Skills.
Description :
Responsible for researching and investigating member complaints, appeals and State Hearing cases.
Responsible for processing Provider Dispute Requests.
Corresponded with the HealthPlan members, providers, outside entities and other HealthPlan departments to resolve issues.
Responsible for handling the department's complex grievance cases.
Created templates and desktop procedures for streamlining the department workflow.
Responsible for training staff on changes to policies and procedures.
Handled process improvement projects of the department.
Experience
5-7 Years
Level
Executive
Education
MA
Grievance Coordinator Resume
Headline : A problem-solver who takes an analytical approach when looking at issues. I am a firm believer in preventing problems before they become one.
Skills : Planning Skills, Coordinating Skills.
Description :
Processed and resolved assigned complaints, properly identifying expedited cases and proper adjudication per expected timeframes, make outbound calls to members/providers/designees regarding and discussing the status of their grievance as well as extracting more information as needed.
Responsible for ensuring effectuations are completed within timeframe and notification is given per regulatory requirements while balancing the need to produce high quality work related to complex and sensitive members issues.
Responsible for maintaining grievance information and supporting documentation in according with regulatory bodies for all lines of business.
Responsible and accountable for maintaining knowledge of the current regulatory standards and policies.
Maintained knowledge of the information on members' benefits and material.
Consulted with other departments, identify and forward potential HIPAA Privacy Issues to the Privacy Officer.
Identified and forward potential quality of care (PQI/PQOC) cases to our Medical Review Board.
Experience
5-7 Years
Level
Executive
Education
Associates Of Science In Accounting
Grievance Coordinator Resume
Objective : To obtain a Project Manager or Coordinator position with a company where I can develop and implement my project management skills coupled with excellent communication and organization.
Skills : MS Office, Customer Service.
Description :
Picked up offender grievances daily throughout the facility.
Read an process all emergency issues first then continue to do data entry in computer on gr00 computer system.
Created worksheet for staff responses.
Daily closed creating a response from data an documents received.
Assisted an supervise clerk in office doing match ups,filing,faxing copying, sorting through mail doing data entry for closing an incoming mail to be sent by to offenders.
Weekly reported done for grievances of totals open,closed,and with extensions.
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