Grievance Resolution Specialist
Grievance Resolution Specialist
Employer Active
Job Alert
You will be updated with latest job alerts via email
Share
Job Alert
You will be updated with latest job alerts via email
1-3years
Not Disclosed
Salary Not Disclosed
1 Vacancy
Job Description
Grievance Resolution Specialist
Position Summary: The ideal candidate shall hold the relevant bachelor s degree and 5 years of experience in professional editing and writing.
Work Duration: Up to 6 months
Job Type: Onsite
Position Responsibilities
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 organization s 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 the Quality Improvement department as applicable and facilitates responses to members according to CalOptima Health policy.
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.
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.
Completes other projects and duties as assigned
Experience & Education
Associate s degree in business health care administration or related field required.
1 year of experience in any of the following areas: Grievances and Appeals Claims Regulatory Compliance Customer Service or related field required.
Experience in health care practice standards for both government and commercial plans strongly preferred.
Bilingual in English and one of the following languages: Arabic Farsi Chinese Korean Spanish or Vietnamese
An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.
Necessary Attributes:
- Develop rapport and establish and maintain effective working relationships with 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 job specific applications/systems to produce correspondence charts spreadsheets and/or other information applicable to the position assignment
Please see HR for information on physical demands and work environment of this job.
Sunshine Enterprise USA is an Equal Opportunity Employer Minorities Females Veterans and Disabled Persons
2 years of experience in project coordination, translations or interpreting services required. 2 years of experience in health maintenance organization (HMO), Medicare, Medi Cal/Medicaid and health services. 1 year of experience with a health plan or working with culturally diverse populations strong preferred. Bilingual in English and one of Arabic, Chinese, Farsi, Korean, Spanish, or Vietnamese. Professional education in project management, translation, interpretation or cultural competency training preferred. Experience in managed care and/or government programs preferred.
Employment Type
Full Time
