Job Description:

Grievance and Appeals Specialist

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 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 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.
• 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.

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.