Job Description:

TEMP - Grievance Resolution Specialist

Job Summary

The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, and 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 discussions with operational experts to result in a final case disposition as needed.
• Evaluate case details, propose recommendations, or make decisions as applicable; ensure 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 the 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 causes 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”