TEMP - Grievance Resolution Specialist
Job Summary
The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions. The incumbent has frequent external contact with members and families, healthcare providers, health networks, third-party administrators, and regulators. The incumbent collaborates with internal departments such as Customer Service, Provider Operations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.
Position Responsibilities
- Maintains adequate information in our health systems; ensures data collection, summarization, integration, and reporting which includes case creation and management and events/activity tracking.
- Gathers pertinent information regarding the grievances and appeals received, including, but not limited to, member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.
- Coordinates and/or participates in case discussion with operational experts to result in a final case disposition as needed.
- Evaluates case details, proposes recommendations, or makes decisions as applicable; ensures organization decision is implemented according to the Grievance and Appeals policies and case resolution.
- Develops resolution letters and correspondence to members and providers.
- Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.
- Initiates referrals to Quality Improvement department as applicable and facilitates responses to members according to our health policy.
- Assists with Health Networks compliance process.
- Identifies trends and root cause of issues; proposes solutions or escalates ongoing issues to management.
- Meets performance measurement goals for Grievance and Appeals Resolution Services.
- Completes other projects and duties as assigned.
Possesses the Ability To:
- Exercise discretion in processing confidential information.
- Identify critical issues and make recommendations or decisions by using critical thinking skills.
- Document and present case research findings and formulate resolution letters.
- Communicate clearly and concisely both, orally and in writing.
- Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience & Education
- High School diploma or equivalent required.
- 1 year of experience in any of the following areas: Grievances and Appeals, Claims, Regulatory Compliance, Customer Service, or related fields required.
- An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Preferred Qualifications
- Associate degree in Business, Health Care Administration, or related field.
- Experience in healthcare practice standards, for both government and commercial plans.
- Bilingual in English and in Arabic, Farsi, Chinese, Korean, Spanish, or Vietnamese.
Knowledge of:
- State and Federal regulations regarding the healthcare industry.
- Managed Care industry, health care, Medi-Cal/Medicaid, and Medicare processes.
- Appeals and Grievances operating procedures and processes strongly preferred.
At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits:
Competitive pay & weekly paychecks
Health, dental, vision, and life insurance
401(k) savings plan
Awards and recognition programs
Benefit eligibility is dependent on employment status.
Sunshine Enterprise USA is an Equal Opportunity Employer Minorities, Females, Veterans and Disabled Persons
Possesses the Ability To: Maintain accurate records and documentation. Contribute to the development of a plan based on assessment of the member s physical, psychosocial, functional, strengths/barriers, and mental health needs. Establish and maintain effective working relationships with leadership and staff. Communicate clearly and concisely, both orally and in writing with individuals from a diverse population. Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment. Experience & Education: High School diploma or equivalent required. 1 year of experience working with the needs of seniors or persons with disabilities (SPD) in a customer/member service capacity required. Bilingual in English and one defined threshold languages (Arabic, Chinese, Farsi, Korean, Spanish, Vietnamese) required. An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying. Valid driver s license and vehicle, or other approved means of transportation, an acceptable driving record, and current auto insurance will be required for work away from the primary office 20% of the time or more. Preferred Qualification: Bachelor s degree in healthcare management or a related field. 1 year of Health Maintenance Organization (HMO), Medi-Cal, and/or health services experience. Knowledge of: Principles and practices of health care service delivery and managed care, Medi-Cal, Long-term services and supports.