Grievance Resolution....
Grievance Resolution Specialist
Posted on :
05-06-2024
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Job Description
Client: CalOptima Health
Job Title: Grievance Resolution Specialist
Duration: 06 Months
Start Date: ASAP
Location: 505 City Parkway West CA (Onsite)
Position Type: Contract
Interview Type: In Person/Web Interview
Ceipal ID: CALGAN531BT
Job Summary
CalOptima Health is seeking a highly motivated and experienced TEMP Grievance Resolution Specialist to join our team. The Grievance Resolution Specialist will be responsible for coordinating the grievance and appeal resolution process. The incumbent will respond to verbal and written grievances and appeals from members and providers relating to member eligibility and benefits contract administration claims processing utilization management decisions and pharmacy and vision decisions. The incumbent will have frequent external contact with members and families health care providers health networks third party administrators and regulators. The incumbent will collaborate with internal departments such as Customer Service Provider Relations Pharmacy and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.
Duties & Responsibilities:
- 80% Program Support
- Participates in a missiondriven culture of highquality performance with a member focus on customer service consistency dignity and accountability.
- Maintains adequate information in CalOptima Healths systems; ensures data collection summarization integration and reporting including case creation and management and events/activity tracking.
- Gathers pertinent information regarding the grievances and appeals received including member or provider concerns supporting information related to initial decisionmaking new information supporting the grievance or appeal or supplemental information required to evaluate grievances and appeals within regulatory requirements.
- Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed.
- Evaluates case details proposes recommendations or makes decisions as applicable ensures the organizations 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.
- 15% Administrative Support
- Assists the team in carrying out department responsibilities and collaborates with others to support short and longterm goals/priorities for the department.
- Assists with health networks compliance process.
- Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS).
- Identifies trends and root cause of issues proposes solutions or escalates ongoing issues to management.
- 5% Completes other projects and duties as assigned.
Minimum Qualifications:
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 field required.
Preferred Qualifications:
- Associates degree in business health care administration or related field.
- Experience in health care practice standards for both government and commercial plans.
- Bilingual in English and in one of CalOptima Healths defined threshold languages (Arabic Farsi Chinese Korean Spanish Vietnamese).
Knowledge & Abilities:
- Develop rapport and establish and maintain effective working relationships with CalOptima Healths leadership and staff and external contacts at all levels and with diverse backgrounds.
- Work independently and exercise sound judgment.
- Communicate clearly and concisely both orally and in writing.
- Work a flexible schedule; available to participate in evening and weekend events.
- Organize be analytical problemsolve and possess project management skills.
- Work in a fastpaced environment and in an efficient manner.
- Manage multiple projects and identify opportunities for internal and external collaboration.
- Motivate and lead multiprogram teams and external committees/coalitions.
- Utilize computer and appropriate software (e.g. Microsoft Office: Word Outlook Excel PowerPoint) and jobspecific applications/systems to produce correspondence charts spreadsheets and/or other information applicable to the position assignment.
V Group Inc. is an IT Services company that supplies IT staffing project management and delivery services in software network help desk and all IT areas. Our primary focus is the public sector including state and federal contracts. We have multiple awards/ contracts with the following states: CA FL GA IL KY MD ME MI NC NJ NY OH OR PA SC TX VA and WA. If you are considering applying for a position with V Group or partnering with us on a position please feel free to contact me with any questions you may have regarding our services and the advantages we can offer you as a consultant.
Please share my contact information with others working in Information Technology.
Employment Type
Full Time
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